Resilience is not about trying harder
Resilience has become a buzzword that not everyone likes. Used superficially it can heap more pressure on individuals. Embraced properly, it means organisations creating conditions in which nurses can be kind to themselves.
Resilience has become a buzzword that not everyone likes. Used superficially it can heap more pressure on individuals. Embraced properly, it means organisations creating conditions in which nurses can be kind to themselves
As an assistant chief nurse, Paul Jebb has a busy and demanding job.
At this time of year in particular, with winter pressures in the headlines, it would not be surprising if he was working relentlessly, skipping lunch and breaks, never switching off – and expecting nursing teams to do the same.
However, that couldn’t be further from Mr Jebb’s philosophy. ‘The NHS is under pressure all year round. As part of my job, I try to ensure that we’re building resilience in our nursing teams, and as senior nurses that means making sure we manage our own resilience too.’
He emphasises that maintaining resilience and enhancing well-being require commitment and funding from organisations. Making sure that staff can take the breaks they need is part of that ethos, and safe staffing levels are obviously an important element.
His employer, University Hospitals of Morecambe Bay NHS Foundation Trust, offers courses and other support to staff on the front line and at senior management level. He recently took part in a mental health first aid course.
The trust has made the Headspace app, which guides meditation and mindfulness sessions, available to staff, allowing them to boost their health and well-being at their own pace. It also has a Flourish at Work programme that encourages staff to move more, nourish themselves, be mindful and look after their heart health. ‘It’s about physical and emotional health,’ says Mr Jebb.
He makes sure he goes to the gym and has time with friends, and has started meditation as part of his trust's initiative with Headspace.
Resilience is a term that has gained currency in nursing, in the health service and in society more widely. It’s a word that sounds strong – governments use it, for example, when trying to show that cities and nations can cope with dangers brought by terrorism, or adverse weather.
But not everyone agrees that it is wise to focus on resilience in nursing, especially as there is still debate about what it means or involves.
Michael Traynor, professor of nursing policy at the Centre for Critical Research in Nursing and Midwifery at Middlesex University in London, says the idea of the resilient nurse can be used by management to excuse failing to staff services properly.
‘We must resist the idea that if a nurse tried a bit harder she’d be able to bounce back. I’d rather see organisations asking how they, as organisations, can be more resilient’
Michael Traynor, professor of nursing policy and author
‘I think nurse research into resilience is well-meaning, but can be naïve,’ he says. ‘It’s playing into the hands of those who want to put responsibility for system failure onto individuals. It’s a very individualised concept, and has been taken up uncritically by too many people.’
Professor Traynor, the author of Critical Resilience for Nurses, published last year, has looked into the area in more detail than most.
While there are individual and organisational benefits to having a resilient workforce, he says it should be a jumping off point for political activism and making the case for change – ensuring appropriate numbers of staff and reasonable working conditions.
He believes nurses face different forms of stressors, one being the nature of the job, which involves dealing with patients and their families during difficult periods, and the other the ‘adversity’ that results from poor political decision-making or management, or under-staffing.
Fallacy of bouncing back
While individual nurses may have some responsibility for ensuring they can cope with the first part, the adversity is outside their control.
‘We must resist the idea that if a nurse tried a bit harder she’d be able to bounce back. I’d rather see organisations asking how they, as organisations, can be more resilient,’ says Professor Traynor.
Whatever it is called, most people would agree that supporting staff is a good thing. But despite the amount of academic research on the value of resilience in nursing, the NHS has not adopted the concept wholesale.
‘I think there are pockets of NHS organisations that recognise it,’ says Mr Jebb. ‘But it should be part of the whole agenda on how we support staff, and how we reduce absenteeism. It’s important that we show that staff are supported and valued.’
Joanna Goodrich is head of evidence and learning at the Point of Care Foundation, which promotes improvements in the way people are cared for and supports staff who deliver care.
She is lead author of Resilience: A framework supporting hospice staff to flourish in stressful times, published by Hospice UK in 2015, and believes its recommendations are applicable to the health service more widely.
‘The most surprising finding still remains true today, and that is that people who work in hospices are not stressed so much by the nature of the work, but by poor people management. That applies more broadly to how staff in other settings feel about going into work. Better management skills are needed.’
‘Family’ at work
This is not only true at an organisation level, says Ms Goodrich, adding that research has shown that team leaders have an important role in how supported staff feel. ‘If the immediate work circumstances are good, it can buffer you against all the other things that are going on in an organisation,’ she says.
‘If team leaders are supported to manage staff well, that makes a huge difference. Having the feeling that they have a “family at work” helps their resilience.’
This is not a lesson that has been applied across the NHS with any consistency, she suggests. ‘We do tend to hear about the good organisations, but I have personally been shocked by some of the things I’ve heard when I’ve been out and about working with staff,’ she says.
‘There was one community team of nurses working with patients at the end of life. They were visiting patients on their own and there was no supervision, no opportunity for a debrief – there weren’t even team meetings. Nurses were left alone with their emotions – sadness at the patient’s situation, but also frustration because they couldn’t do more.’
More support for staff
Ms Goodrich would like to see organisations take more action to support staff, but says it doesn’t necessarily have to be called ‘resilience’.
‘I do feel it’s become a bit of a buzzword – we should be looking at other things, such as reflective practice and supervision and Schwartz rounds. If an organisation has Schwartz rounds in place, they’re sending out the signal that staff can take an hour out for themselves – and providing the conditions for staff to be resilient.’
Mr Jebb says it’s time for action. ‘In 2018 there needs to be a system-wide recognition of how we build resilience across the whole health and care system,’ he says.
‘Pressure isn’t necessarily always a bad thing, but we need to ensure that staff are equipped and supported if we are to have resilient organisations, at any time of year.’
Defining resilience in nursing
Resilience is defined as ‘the capacity to recover quickly from difficulties; toughness’, or ‘the ability of a substance or object to spring back into shape; elasticity’. The first of these dictionary definitions refers to organisations or individuals, the second to inanimate objects – indeed, the sample sentence refers to the resilience of nylon.
Resilience as we understand it today probably has its origins in thinking by child psychologists in the 1970s and 80s. Previous work had focused on the negative consequences of poor life circumstances, but these thinkers wanted to find out about the children who appeared to be able to adapt and overcome the worst of situations.
The focus on protective factors in individuals has since been broadened to organisations and specific industries and sectors, including health.
In an article in Nursing Management in 2017, Paul Jebb cites research suggesting that resilience building involves assessment, acceptance, adaptation and advancement. He says: ‘The abilities to assess events, accept their impact, adapt to new circumstances and take action to build up resilience again, ready for the next challenge, could be built into reflective practice so learning can be timely and self-led.’
Recommendations for developing resilience
The Point of Care Foundation report for Hospice UK makes the following recommendations for engaging staff and developing resilience:
- Establish supervision arrangements.
- Seek out problems and target support for them.
- Assess training needs and plan education and training of staff and volunteers in relation to resilience.
- Create space for staff to reflect on patient care challenges, such as Schwartz rounds.
- Set coherent goals for quality and safety from board to ward.
- Articulate values and show how they translate into behaviour.
Schwartz rounds: replacing burnout with compassion
Dozens of healthcare organisations across the UK and the Republic of Ireland have introduced Schwartz rounds with the aim of supporting staff and ultimately improving patient care and experience.
The ‘rounds’ are meetings at which staff from all disciplines and levels can come together to discuss the emotional and social aspects of working in healthcare.
According to the Point of Care Foundation, which implements Schwartz rounds in the UK, the underlying premise is that compassion shown by staff can make all the difference to patients’ experience of care, but in order to provide compassionate care staff must feel supported in their work.
Less isolated, more supported
The rounds follow a structured format with sessions generally once a month and lasting for an hour, and involve clinical and non-clinical staff sharing their experiences.
The Point of Care Foundation says rounds can help staff feel more supported in their jobs, allowing them the time and space to reflect on their roles.
Evidence shows that staff who attend the sessions feel less isolated and more supported, and that it can also break down hierarchies and give staff a better understanding of each other’s jobs and challenges.
Schwartz rounds are named after healthcare attorney Ken Schwartz who was diagnosed with terminal lung cancer in 1994. During his treatment he found that it was acts of kindness from caregivers that ‘made the unbearable bearable’. He left a legacy to establish the Schwartz Centre in Boston to foster compassionate care.
Jennifer Trueland is a freelance journalist
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