Resilience is a concept where people are encouraged to re-frame negative experiences or stressors so that they become a fundamental occasion for personal growth (Gill and Orgad, 2018). Central to this is the development of resilience and empowerment, both being attributes that can enable the individual to cope in stressful situations (Pines et al, 2017).
Resilience has been extensively explored in the nursing literature and is considered an essential characteristic of nurses (Scammell, 2017; Kester and Wei, 2018). Physicians who report a greater level of career satisfaction are more likely to be associated with a greater level of patient satisfaction (DeVoe et al, 2007), while nurses who report increased levels of resilience are more inclined to report higher levels of patient care (Williams et al, 2016). Disappointingly, reports have told of catastrophic failings in healthcare, in which nurses have been implicated (Francis, 2013; Kirkup, 2015). The profession has come under scrutiny as the goal to fix nursing gains impetus (Strickland, 2018). This is no more evident than with the new pre-registration nursing standards (Nursing and Midwifery Council (NMC), 2018a) and the continued challenge to degree nursing status (Strickland, 2018). Despite these perceived failings and poor practices, many nurses have adopted a stoic approach and continue to tolerate working under immense pressure, often in conflicting and stressful environments. This situation, if allowed to continue, ultimately leads to burn out (Haik et al, 2017) and ‘compassion fatigue’ – which occurs as a result of the nurses' decreasing capacity to express empathy due to continual exposure to the suffering of others (Peters, 2018).
Promoting mental health
The NHS Staff and Learners' Mental Wellbeing Commission (Health Education England (HEE), 2019) reported that further research is needed into the causes of distress, fatigue, self-harm and suicide among health professionals, with female nurses and male paramedics in particular considered to be at significant risk. Regrettably, the stigma associated with poor mental health can create serious barriers to the access of quality care (Knaak et al, 2017).
The HEE (2019) commission considered the impact that poor mental health could have on maintaining positive health and wellbeing, and presented an ambitious plan to not only support people in times of adversity, but also in times of transition. Unfortunately, the work being undertaken is somewhat insufficient due to the failure to recognise the importance of social interactions in promoting resilience (Lee et al, 2015). There is also a failure to recognise the importance of nurse leaders educating more junior nurses on the importance of self-care (Kester and Wei, 2018) and in particular supporting self-actualisation (Maslow, 1943).
Nurses continue to live in a culture that prohibits the development of personal coping strategies and of a healthy and resilient nursing workforce. In order to ensure the health of nurses, argued Kester and Wei (2018), leaders must adopt new approaches to promoting the wellbeing of the nursing workforce, examples of which include the recognition of personal stressors, the provision of social support and the implementation of meaningful recognition, perhaps through awards or even tokens of gratitude. Developing a strategy that promotes mindfulness as a holistic intervention has the potential to benefit nurses' wellbeing (White, 2014).
Mindfulness
Having the ability to practise mindfulness, argued Cusack et al (2016), is an important step in helping nurses to step back from an emotionally charged situation, and in so doing create an opportunity for reflection, learning and moving forward. Several views commend the value of developing resilience through reflection (Kinman and Grant, 2011; McDonald et al, 2012). This requires gaining an understanding of another's suffering, being ready and willing to help, promoting wellbeing and enabling the sufferer to seek a solution to their problem (Perez-Bret et al, 2016).
However, developing resilience can be particularly challenging in nursing, a role in which uncertainty and the need for effective decision-making are constant (Scammell, 2017). Being able to effectively manage personal mental and physical health is as essential as caring for a patient's health (Lloyd and Campion, 2017). Mills et al (2015) advocated that the inability to demonstrate self-care, kindness and compassion to oneself has the potential to compromise and demonstrate compassion to others. The role of nursing is changing and the demand for nurses and the need to deliver care to patients with increasingly complex care needs is greater than ever (Cummings, 2016). Furthermore, as nurses move to new roles, in clinical and non-clinical environments, the transition that occurs can be particularly challenging as they begin to experience doubt, unfamiliarity and a sense of unease (Sellman, 2018).
Transition
The impact of transitioning from a student to registered nurse is extensively reviewed in the nursing literature, (Higgins et al, 2010; Blevins, 2018). Transitions begin very early in a career, including leaving school and going into further and then higher education and ultimately into a professional role (HEE, 2019). Transitioning positively necessitates an intrinsic understanding of oneself; self-care training and signposting to services as and when required can help to ensure periods of transition occur smoothly and effectively (HEE, 2019).
A recurring theme in the literature is the inability of student nurses to effectively transition to the role of registered nurse, as many find it challenging to fit into their new workplace environment (Laschinger et al, 2016). The experience of moving from pre-registration to registered nurse is often recognised as ‘transition shock’ (Duchsher, 2009) and is something that can cause many nurses to experience significant distress. Such transitions are often fraught with a wide-ranging and diverse range of emotions including anxiety, dread, emotional exhaustion and helplessness (Ebrahimi et al, 2016). For many nurses, this is a time when they can feel at their most vulnerable and experience feelings of insecurity and self-doubt as they adapt to the increasing responsibilities, leading to the ‘imposter phenomena’ also known as ‘imposter syndrome’ (Clance and Imes, 1978), although research indicates that nurses of all levels can experience this (Christenson et al, 2016). Imposter syndrome refers to highly successful individuals who are unable to recognise their achievements and have a constant fear of being uncovered or exposed as a fraud.
Keeping newly qualified nurses in the job is vital to improving staff shortages, and building resilience plays a significant role in retention
Taking the lead
New graduate nurses often encounter a significant period of stress (Waddell et al, 2015) and as a result they are leaving their initial employment at a disturbing rate (Cheng et al, 2014). The level of attrition in new graduate nurses, together with the rate of retirement of late-career nurses, compound the problem of nurse shortages (Waddell et al, 2015). There have been significant changes to nurse education, including:
- The new pre-registration nursing standards (NMC, 2018a)
- The fast track Nurse First programme (NHS England, 2017)
- The nursing associate role (Darbyshire, 2018)
- Nursing apprenticeship programmes (Department of Health and Social Care, 2016)
- The changes to nursing bursaries, strongly lobbied for by the Council of Deans (Glasper, 2016).
Therefore, it could be argued that the nursing profession is in a significant phase of transition, with nurses doing their best to navigate the journey ahead. This requires nurses to adopt new approaches to managing the challenges. The nursing profession must step up and, through strong leadership, support its members in the nursing environment, whether clinical or non-clinical. This requires nursing leaders to promote positivity, become effective role models, encourage the sharing of positive experiences, capitalise on nurse's strengths and encourage self-care (Wei et al, 2019). Otherwise, it is likely that the future of nursing will remain uncertain.
Challenges from within
Nurses have been found to be able to furtively or openly direct their dissatisfaction towards each other and those deemed less powerful (Griffin, 2004), creating a situation called ‘lateral violence’ (Iheduru-Anderson, 2014). The future of nursing practice requires nurses, nurse managers, nurse educators both in further and higher education, clinical nurse educators and researchers to be cognisant of the importance of a resilient workforce that is able to meet the needs of service delivery and patient care. It requires the workforce to be part of the solution to ending lateral violence rather than being complicit in its problems (Egues and Leinung, 2013).
Furthermore, increasing challenges that threaten the nursing profession present a narrative through which nurses lose hope and leave. The reasons for this are complex, although Chan et al (2013) in their research on nurse shortages and intention to leave, highlighted two major factors: organisational and individual. Organisational factors are those that are directly related to the working environment and include workplace culture, professional demands, commitment of others, and the social support provided. Individual factors relate to those that directly impact the self and include demographic factors such as age, gender, education and marital status, personal job satisfaction and burnout, all of which can have a profound effect on intention to leave (Chan et al, 2013). Although Chan et al (2013) identified limitations to their research, they argued that nurse managers now have insight into the risks associated with nurses intention to leave. This knowledge empowers them to act to address the significant threat to nurse shortages and improve the quality of care.
In order to limit this exodus, improving the emotional resilience of the nursing workforce is one argument, with individuals being expected to take more personal responsibility by adopting a resilient approach to their professional practice, irrespective of the challenges faced (Barratt, 2018). However, nurses should not be expected to shoulder every burden. The problem is part of a perpetuating global challenge, that of developing and maintaining a skilled workforce – one with the capability and aptitude to effectively manage the increasing pressures on the workforce (Jones and Sherwood, 2014).
However, simply focusing on the ability of individuals to manage increasing challenges and precarious situations, irrespective of the adversity, averts attention from the shared responsibility to safeguard individuals (Barrett, 2018). This means that failure to manage challenges is considered a failing by the individual, who has neglected to develop sufficient resilience, rather than considering the impact of social attitudes and public policy (Barrett, 2018; Gill and Orgad, 2018). Therefore, this leads to nurses being failed by the very people who should provide them with support – other nurses. This lack of support often leaves nurses in crisis and unable to recover sufficiently to return to everyday professional practice. A sad indictment when caring is considered a fundamental aspect of nursing (Warshawski et al, 2018).
‘Simply focusing on the ability of individuals to manage increasing challenges and precarious situations, irrespective of the adversity, averts attention from the shared responsibility to safeguard individuals (Barrett, 2018). This means that failure to manage challenges is considered a failing by the individual, who has neglected to develop sufficient resilience, rather than considering the impact of social attitudes and public policy (Barrett, 2018; Gill and Orgad, 2018)’
Conclusion
Developing resilience among nurses has the potential to safeguard the health and wellbeing of the nursing population, sustain the workforce and ensure the provision of high-quality care (Barrett, 2018). Furthermore, building resilience can help students to thrive professionally and become able to face life events and challenges with a sense of hope and confidence, all while promoting enhanced wellbeing and long-term career sustainability (Stephens, 2013).
Being able to promote positivity means supporting nurses to see situations from a constructive and optimistic perspective. This approach has the capacity to facilitate social connections, which in turn can improve nurses' engagement and build positive relations with others, providing nurses with a healthy work environment and thereby improving resilience (Wei et al, 2018).
The importance of ensuring effective transitions into new work roles has been explored, as has imposter syndrome, self-awareness, resilience and mindfulness. Just as we all have physical health, we also have mental health. It is important that we endeavour to achieve mental wellbeing (HEE, 2019), as we would physical health. It is normal that from time to time we will be firing on all cylinders, and at others we will not. Ensuring that one part of our life is working well often means that we can cope better when something goes slightly awry. So while facing these challenges, it is relevant to ask – who is caring for the carers?
KEY POINTS
- Resilience is a key attribute of nurses
- Compassion fatigue occurs when exposed to the suffering of others
- Adopting mindfulness can promote nurses wellbeing