By Shelley Jones

The learning activity is relevant to professional competencies related to your responsibilities for meeting professional and ethical standards (e.g. Nursing Council of New Zealand Registered Nurse competencies 1.1, 1.4) and relationship responsibilities with patients/clients and colleagues (Registered Nurse competencies 2.8, 2.9, 3.1, 3.2).


Learning outcomes

Reading and reflecting on this article will enable you to:

  • think critically about resilience in relation to your work life
  • understand basic concepts related to resilience
  • review factors that promote resilience in order to highlight the factors you already use and those you can adopt or adapt.

Introduction

Resilience has been described as the ability to withstand, recover or ‘bounce back’ from adversity or threat. It is a concept applied across ecology, social sciences, technology and engineering – but does that make resilience just another idea that’s everywhere? At a personal level, is it optimism, gratitude and grit in equal measure? And how does it work when the situation you find yourself in is really very difficult?

Stress and adversity at work

For most of us, the adversities we encounter do not constitute major disasters but rather are more modest disruptions that are embedded in our everyday lives.1

…to demonstrate resilience, one must first encounter adversity… Workplace adversity can be viewed as a negative, stressful, traumatic or difficult situation or episode of hardship that is encountered in the occupational setting … in nursing [it] is associated with excessive workloads, lack of autonomy, bullying and violence and organisational issues such as restructuring.2

Resilience for health professionals has been defined as ‘the ability to maintain personal and professional wellbeing in the face of ongoing work stress and adversity.’3 Working in healthcare necessarily places us among people dealing with ‘…pain, loss, fear, disfigurement, death, grieving, challenge, growth, birth and transition…4’ – a privileged place that can be as intellectually and emotionally challenging as it is rewarding. Demographic pressures (an ageing population), epidemiological trends (an increase in long-term conditions) and rising costs of healthcare threaten to overwhelm health services as we know them.5 These pressures in the larger context impact on the work lives of health professionals and patient safety.

It’s being reported increasingly that those delivering health services are themselves feeling overwhelmed and burnt out by excessive workloads.6 It’s also advocated that improving the work life of health care team members7 is a prerequisite for achieving the ‘Triple Aim’ of quality improvement at individual, system and population levels; the relationship between nurses’ work environments and patient outcomes has long been an evidence-based concern.8,9

Although each of us will appraise and respond differently to stressors, workplace stress is linked to negative individual outcomes such as depression and anxiety, burnout, secondary traumatic stress and compassion fatigue, and negative organisational outcomes such as reduced work performance, high turnover and compromised patient care.10

It’s not surprising that the idea of resilience holds appeal – for individual health professionals as well as their managers – as those who score more highly on measures of individual resilience also score more highly on measures of psychological functioning and wellbeing and vice versa.10


Resilience as a process of positive adaptation

But what is resilience exactly? Five perspectives

An integrative review of the empirical literature on resilience determined five distinct themes, each of which add different perspectives and resonances.11 All contain the two core constructs of resilience: significant adversity and positive adaptation.12


Rising above
Resilience is the capacity or strength to endure and overcome hardship or adversity without negative consequences or being undermined. In this perspective, resilience means maintaining equilibrium and possibly even flourishing and thriving in times of difficulty. The process of meeting the challenge may result in a higher level of functioning than prior to experiencing crisis or trauma.

Adapting and adjusting
Resilience is being able to adjust or adapt positively to new or difficult situations – not only major life events, but also daily hassles – and thus to build competence and confidence in facing adverse situations in a positive manner.

‘Ordinary magic’
Resilience is seen as the flip side of risk in this perspective, based on studies of children and adolescents whose development is threatened by external factors such as disadvantage and adversity. Rather than requiring rare and special qualities, ordinary protective factors such as family, love and close friendships support resilience as part of the ‘magic’ of normal everyday human functioning and adaptation.13,14

Good mental health
Resilience and vulnerability can be seen as different dimensions determined by internal factors such as sense of security, self-esteem and self-efficacy.15 In this perspective, resilience is a proxy for positive mental health or absence of psychopathology and reflects an ability to cope with stress. Increasing stress-coping ability can help alleviate or ward off anxiety, depression and other unhelpful reactions to stress.

Bouncing back
Resilience in this perspective is linked to the Latin resilire, formed from re (back) and salire (jump, leap, spring, bound). It also alludes to materials science, where resilience is the ability of a material to absorb and then release energy without being deformed.16 The idea is to ‘bend, but not break’ under stress or in adversity, to recover and return to one’s usual level of functioning.

And is resilience something that you have or something you do?

Rather than a set of stable, unchanging personality traits (which you may or may not have), resilience has been shown to be a personality style of stress resistance or hardiness.
This style is based on three existential ways of being in the world, which can be supported and strengthened or developed to buffer adverse and stressful events:

  • Commitment to oneself and others, and being fully involved in what one is doing as having purpose and meaning.
  • Control as the belief that one can influence one’s surroundings and the outcome of events
  • Challenge as the belief that change is normal and that one can learn and grow from both positive and negative life experiences.17

A biopsychosocial model argues that resilience is the interaction between an individual’s biological disposition (such as tendencies to heightened emotional reactivity) and their particular environmental and social circumstances.

Resilience is associated with being less likely to experience negative emotional states (anxiety, depression, anger, guilt); being mindful (detaching from the emotional response to an event, reflecting and acting with awareness); self-efficacy (believing one can achieve a given task) or personal competence; and using positive coping strategies (instead of negative strategies such as avoiding, disengaging, being passive, substance use).10

Positive coping strategies can be either externally directed, actively solving problems, or internally directed, focusing on emotions e.g. reframing stressful events as short-lived or as opportunities.

Finally, thinking of resilience as ‘…a process of harnessing resources to maintain wellbeing’ requires the consideration of resources available in a person’s cultural context and culturally determined meanings of wellbeing.18 Indeed, the notion of resilience as a individualistic personal property is itself culturally determined and other perspectives, such as whānau resilience,19 must be part of an inclusive approach to resilience at work.

Can you develop resilience?

Increasingly a dynamic and developmental concept of resilience is being emphasised – it is seen as an interactive process between an individual’s personal resources and circumstances, in which they adapt positively to a particular situation.12

It allows the possibility that you can work on strengthening or developing the protective factors that research findings have associated with resilience, such as optimism, problem-solving, emotional awareness, self-efficacy, self-regulation, flexibility, empathy and supportive relationships.20

More important than determining whether your workplace exposes you to the risk of adversity and the need to be resilient, is the care and fostering of wellbeing you owe your professional self.21 Organisationally the focus should be on the promotion of strengths for all health professionals and working towards resilience-promoting environments as a way to increase positive outcomes of unavoidable stress.3

How to enhance or develop resilience in your worklife

You probably have a good idea of what your general vulnerabilities and protective factors are – see Recommended resources (below) for information and tools that you can use to enhance your strengths or build new ones. For resilience in your professional role, these five strategies are a starting point2:

Build positive and nurturing professional relationships
Feeling that you belong and that you are part of a supportive, respectful team committed to each other – and to what you are doing – is a strongly protective factor (the opposite can only make you vulnerable and isolated).

Take time to acknowledge and connect with those you work with and keep connected with and available to your wider professional network – no-one understands what pressures and challenges health professionals face better than another health professional. Consider joining a group or forum related to your clinical specialty or interest.

  • What you do to include and acknowledge others will help you feel included and acknowledged; the kindness you show others will benefit you.

Maintain positivity
The opposite of learned helplessness (giving up when you believe that nothing you do will make any difference) is learned optimism. Rather than being unjustifiably positive, learned optimism uses ‘non-negative’ thinking to reframe a triggering event as something you can manage.22

Be sure to remember what makes you feel good about your work – for example, making a difference with patients, enjoying your co-workers. Find things that can make you laugh together at work, whether it’s a colleague’s zany spontaneity or black humour.

Develop emotional insight
The first insight is that there is emotional labour involved in the professionally appropriate responses that help patients feel cared for, while concealing or suppressing one’s own emotional responses (distress, frustration, grief etc) to their suffering, vulnerability or poor outcomes.23

Formal debriefing processes are more typically offered in more obviously traumatic experiences, but there’s a place for ongoing ‘checking in’ with yourself and with colleagues. A second area for emotional insight is in relationships with team members.

Seek work-life balance and a sense of purpose at work
An understanding of how your work fits into your identity of ‘who you uniquely are’ means being able to relate it to and integrate it with your personal values, beliefs and commitments, as they are what will sustain you and keep you grounded.

  • You may like to review ideas on work-life balance or try the wheel-of-life exercise
  • Try to notice moments when you feel that your work most aligns with your core values and beliefs and hold those moments dear, or examine moments of least alignment to look at what might need to change.

Take time to reflect and learn from experience
The insight and understanding that comes from informal or structured processes of reflection enhances your sense of growth and becoming.

Limits to promoting staff resilience

… by examining and developing theories and models of resilience, we buy into the idea that this is the way it is, and we need simply to get better at bouncing back and being resilient.24

To see a meaningful change in nurse burnout, leaders must address the factors in the care environment that undermine nurse resilience.25

The discussion around resilience in indigenous peoples, including Māori, has been criticised for assuming that individuals accept responsibility for their disadvantaged position (which may be as the result of colonisation), whereas collective resistance is about ‘… exposing an inequitable distribution of power, and actively opposing negative social, political and economic influences’.24

Drawing a parallel from this for nursing and other health professions, we must collectively identify and resist the forces that impact negatively on our professional effectiveness and wellbeing at work, as promoting personal resilience is not the answer to unsustainable work pressures.

But resistance to the status quo need not be a declaration of war, especially since funders, managers and frontline professionals arguably all want to provide a health service that meets the needs of people in Aotearoa New Zealand.

Rather, resistance means moving from reactively coping with the stresses and strains of work and proactively seeking to build sustainably better work environments. Stakeholders can agree on what needs to change and then collaborate to address current problems and prevent them from recurring.

You may have a part to play in what your workplace does to rebuild or strengthen the care environment. And in starting with you, what perspectives and actions that will keep you well and make you stronger – and thus make your profession and health services stronger – are within your control?

Download the learning activity here >>


Recommended resources

Related to stress at work

Related to wellbeing and self-care

Related to developing resilience


Further reading

For an interesting interdisciplinary dialogue between leading researchers on resilience, read this 2014 panel discussion between Steven Southwick and others on resilience definitions, theory, and challenges.

About the author

Shelley Jones RN BA MPhil works independently in projects that support nurses and their work in many settings, from rural districts to operating theatres to aged residential care. Her background in professional development and interest in patient safety come together in workshops and resources on topics such as personal resilience and positive colleagueship.

Peer reviewers of this article

Heather Casey RN MA (Nursing) is the nursing director for mental health for the Southern District Health Board and is a fellow and past-president of Te Ao Māramatanga New Zealand College of Mental Health Nurses.

Faith Roberts RN BSc (Hons) MA is a staff nurse in Wellington Regional Hospital’s Main Outpatients, whose professional interests include how we support nurses in frontline roles.

Stacey Wilson RN MPhil PhD is a senior lecturer at Massey University’s School of Nursing, whose special research interests include mental health and emotional competence.


References

  1. DAVIS MC, LUECKEN L, LEMERY-CHALFANT K (2009) Resilience in common life: introduction to the special issue. Journal of Personality 77(6) 1637-44.
  2. JACKSON D, FIRTKO A, EDENBOROUGH M (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. Journal of Advanced Nursing 60(1) 1-9.
  3. McCANN CM, BEDDOE E, McCORMICK K, HUGGARD P et al (2013) Resilience in the health professions: a review of recent literature. International Journal of Wellbeing 3(1) 60-81.
  4. BENNER P, WRUBEL J (1989) The primacy of caring: stress and coping in health and illness. Addison-Wesley, Menlo Park CA.
  5. MORDEN A, JINKS C & ONG BN (2012) Rethinking ‘risk’ and self-management for chronic illness. Social Theory and Health 10(1) 78–-99.
  6. FRELLICK M (2018) Experts detail proposals to improve clinician well-being. Retrieved December 2018 www.medscape.com/viewarticle/905656
  7. BODENHEIMER T, SINSKY C (2014) From triple to quadruple aim: care of the patient requires care of the provider. The Annals of Family Medicine 12(6) 573-6.
  8. KURTZMAN E, FAUTEUX N (2014) Ten years after Keeping Patients Safe: have nurses’ work environments been transformed? Robert Wood Johnson Foundation Charting Nursing’s Future Publication 22.
  9. McHUGH MD, KUTNEY-LEE A, CIMIOTTI JP, SLOANE DM et al (2011) Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs 30(2) 202-10.
  10. REES CS, BREEN LJ, CUSACK L, HEGNEY D (2015) Understanding individual resilience in the workplace: the international collaboration of workforce resilience model. Frontiers in Psychology 6 (73) 1-7
  11. ABURN G, GOTT M, HOARE K (2016) What is resilience? An integrative review of the empirical literature.  Journal of Advanced Nursing 72(5) 980-1000.
  12. LUTHAR SS, LYMAN EL, CROSSMAN EJ (2014) Resilience and positive psychology. In Lewis M, Rudolph KM eds, Handbook of Developmental Psychopathology. Springer, Boston MA. pp125-140.
  13. BUHS ES, RUDASILL KM (2016) Review of Ordinary Magic: Resilience in Development by Ann S Masten. Educational Psychology Papers and Publications 220. Accessed December 2018 http://digitalcommons.unl.edu/edpsychpapers/220/
  14. MASTEN AS (2001) Ordinary magic: Resilience processes in development. American Psychologist 56(3) 227-37.
  15. DANIEL B, WASSELL S (2002) Assessing and Promoting Resilience in Vulnerable Children. Jessica Kingsley Publishers, London.
  16. WIKIPEDIA n.d. Resilience (materials science). Accessed December 2018. https://en.wikipedia.org/wiki/Resilience_(materials_science)
  17. KOBASA SC (1982) The hardy personality: toward a social psychology of stress and health. In Sanders GS, Suls J eds, Social Psychology of Health and Illness, Lawrence Erlbaum Associates, Hillsdale NJ. pp1-25.
  18. SOUTHWICK SM, BONANNO GA, MASTEN AS, PANTER-BRICK C et al (2014) Resilience definitions, theory, and challenges: interdisciplinary perspectives. European Journal of Psychotraumatology 5(1) 25338.
  19. WAITI J, KINGI TK (2014) Whakaoranga Whānau: Whānau Resilience, MAI Journal 3(2) 126-139.
  20. REIVICH KJ, SELIGMAN ME, McBRIDE S (2011) Master resilience training in the US Army. American Psychologist 66(1) 25-34.
  21. NURSING COUNCIL OF NEW ZEALAND (2012) Code of Conduct for Nurses. Accessed December 2018 http://www.nursingcouncil.org.nz/Nurses/Code-of-Conduct
  22. SELIGMAN MEP (1991) Learned Optimism. Random House, Sydney.
  23. DELGADO C, UPTON D, RANSE K, FURNESS T et al (2017) Nurses’ resilience and the emotional labour of nursing work: an integrative review of empirical literature.  International Journal of Nursing Studies 70(2017) 71-88.
  24. PENEHIRA M, GREEN A, SMITH LT, ASPIN C (2014). Māori and indigenous views on R and R: Resistance and Resilience. MAI Journal 3(2) 96-110.
  25. VIRKSTIS K, HERLETH A, LANGR M (2018) Cracks in the foundation of the care environment undermine nurse resilience. Journal of Nursing Administration 48(12) 597-9.

 

2 COMMENTS

  1. Hello
    Can I have access to the article
    Personal resilience: developing and drawing on your own resources
    many thanks
    Andy McLachlan NP

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