key: cord-283943-cdjmsdta
authors: Henshall, Catherine; Davey, Zoe; Jackson, Debra
title: Nursing resilience interventions–A way forward in challenging healthcare territories
date: 2020-04-15
journal: J Clin Nurs
DOI: 10.1111/jocn.15276
sha: 
doc_id: 283943
cord_uid: cdjmsdta

Personal resilience has been conceptualised in many different ways; however, a common definition is that resilience is the ability to cope successfully despite adverse circumstances (Henshall, 2020). Historically, the term 'resilience' encompasses both physiological and psychological aspects and the latter is personal to individuals, with some people having more developed strategies for personal resilience than others. Understandings of resilience vary between populations, contexts and cultures (McDonald et al., 2012), with resilience being viewed in some cases as an inherent personality trait and in others as a dynamic process existing on a continuum between resilience and vulnerability.

Personal resilience has been conceptualised in many different ways; however, a common definition is that resilience is the ability to cope successfully despite adverse circumstances (Henshall, Davey, & Jackson, 2020) . Historically, the term "resilience" encompasses both physiological and psychological aspects and the latter is personal to individuals, with some people having more developed strategies for personal resilience than others. Understandings of resilience vary between populations, contexts and cultures (McDonald, Jackson, Wilkes, & Vickers, 2012) , with resilience being viewed in some cases as an inherent personality trait and in others as a dynamic process existing on a continuum between resilience and vulnerability. The former infers that some individuals are more vulnerable or "do not have what it takes" to overcome adversity (Masten, 1994) , whereas the latter suggests that levels of individual resilience can ebb and flow depending on a person's contextual circumstances and environment (Rutter, 1985) . This latter concept of resilience as a fluid process has implications for the way in which we consider resilience in the nursing workforce.

The current very high demand for nurses, exacerbated by the COVID-19 pandemic, has really highlighted the need to ensure a robust and resilient workforce. Current and projected shortfalls in the number of nursing staff that are required for the delivery of high quality care, has compounded the challenge of responding, to better support staff in meeting increased healthcare demand. The pressure is on nurses to provide high quality, complex patient care within the context of scarcer resources in terms of staffing, infrastructure or financial reward (Burmeister et al., 2019) , even in the context of major challenges such as those presented by a pandemic. In addition, nurses commonly experience incidences of workplace adversity that can challenge and impact on their levels of resilience (Hart, Brannan, & De Chesnay, 2014) . Excessive workloads, increased use of casual staff, decreased autonomy, bullying, violence and almost continual organizational change have all been linked to workplace adversity, creating workplaces that can be experienced as hostile, unrewarding and even abusive by nurses. The need to meet service demands under highly pressured, and often suboptimal and even unsafe conditions combined with a lack of career structure or progression, can lead to registered nurses facing stress and burnout. This has resulted in many nurses leaving the workforce at a time when their skills, training and professionalism are most in need (Jackson, Firtko, & Edenborough, 2007; Jennings, 2008) .

In response to the increasing pressures facing nurses working within overstretched and under-resourced healthcare systems, building personal resilience has been identified as being essential in coping with work related stress and adversity, maintaining job satisfaction, engaging in self-care and helping to address problems with workforce retention and staff well-being (Foster et al., 2019; Slatyer, Craigie, Heritage, Davis, & Rees, 2017) . Internationally, multiple resilience enhancement interventions have been developed and implemented in various settings (Craigie et al., 2016; Henshall et al., 2020; McDonald et al., 2012) . However, whilst these interventions have been evaluated positively and have been shown to support personal resilience in the short-term, care must be taken to ensure that these interventions are not viewed as a panacea for the overarching problems facing healthcare services and the resultant challenges to those working within them. Rather, resilience enhancement interventions should be viewed as tools to underpin existing support structures, as a way of helping to promote and sustain resilience levels within the nursing workforce.

Health services need to follow the lead of nurses who are investing in their own personal resilience strategies by providing appropriate system level interventions and support mechanisms; this will not only enhance the personal resilience of individuals, but will also enhance systems resilience in the longer term.

The way in which the concept of resilience is framed within resilience-enhancing interventions is crucial in ensuring that nurses are not deterred from engaging with these interventions due to feeling judged or criticised by colleagues, peers or managers, or due to being deemed fragile, unable to cope or lacking in resilience. The purpose of resilience-enhancing interventions, as mechanisms for reflecting on, building and sustaining resilience needs to be clearly articulated so that nurses do not feel that enrolment on these courses is a sign of failure, incompetence or unworthiness. This may be especially true if nurses have recently been exposed to difficult or challenging situations at work, which may lead to them feeling that they are being exclusively targeted or selected for enrolment to improve their coping abilities. This is encapsualted in an excerpt from a recent study reporting on a workplace resilience enhancement intervention (Henshall et al., 2020) . In this study, a nurse participant summarised their beliefs prior to the intervention about being selected to take part: "I thought I was put on the Resilience Course because my manager didn't think I was resilient enough and that it was a shortfall in my performance". However, once the participant was fully engaged in the program, this perspective shifted, with the participant describing the intervention as "really helpful" because of its focus on "Caring for staff, trying to help you do your job better, and building with the other people there." Whether conceptualised as an inherent trait or a dynamic process, the vast majority of people entering the nursing profession display characteristics that are compatible with the concept of resilience from the outset, such as altruism, vocation, empathy and caring for others (Eley, Eley, & Rogers, 2010) . From the onset of their nursing training student nurses are exposed to a range of clinical scenarios involving patients and clients with complex and diverse health and social care needs. This results in nurses' baseline resilience levels being buffeted, reshaped and reinforced due to rapid exposure to a range of new experiences which may challenge their previously held conceptions and beliefs, leading to almost continual self-reflection and self-critique, and can allow for qualities such as resilience, empathy, and compassion to be developed; such qualities continue to be continuously tested and reinforced throughout a nursing career.

The stresses and strains associated with encountering challenging and difficult situations can be tempered by the satisfaction engendered through the intimacy of the nurse/patient relationship (Williams, 2001) . However, the increasing environmental, financial, cultural, and social workplace pressures impacting on healthcare service provision means that the equilibrium between challenge and reward is becoming increasingly difficult to maintain. Increasingly, there are sacrifices in the quality of care that nurses are able to give to patients, because of pressures on the nursing workforce associated with staffing, vacancies, and increased demands on time. Nurses are central to the patient care pathway and are required to provide emotional, physical, psychological and social support to patients and their families at all times. However, little consideration is given as to the impact of the provision of this support on nurses' emotional well-being, or their ability to maintain a satisfactory work-life balance. Furthermore, limited provisions are in place to provide nurses with reciprocal emotional, physical, psychological and social support. Where these supports are place, for example through peer supervision, reflective practice or mentoring, they are often deprioritised or sacrificed at the expense of more immediate clinical demands.

In response to the international retention and recruitment crises facing nurses, many healthcare systems are focusing on strategies to enhance and sustain the health and well-being of their clinical workforce (Buchan, Charlseworth, Gershlick, & Seccombe, 2019; Health Workforce Australia, 2014) . One example of this is via the United Kingdom NHS National Retention Strategy, launched in 2017 to decrease nursing turnover rates in all hospital trusts (NHS Improvement, 2019); the strategy advocated for more investment in workplace based interventions and training, and the provision of additional mentoring support for nurses and other healthcare professionals. Whilst this is a welcome move, it is imperative that these initiatives are implemented across the whole career trajectory beginning at undergraduate level.

Resilience in nursing must be viewed and acknowledged as a dynamic, fluid process that requires continuous nurturing and commitment, as well as adaptability and flexibility in the face of changing professional and personal requirements. In order for resilience enhancement interventions to be successful system level change is required at an organizational, cultural, team and managerial level.

Resilience-enhancement programmes should be integrated into the overall well-being strategies of healthcare organisations as part of a larger, more comprehensive staff support strategy; these programmes should be evaluated to measure their short-and long-term impact and outcomes (Blake & Lloyd, 2008) . Proactively addressing the need for nurses to maintain, preserve and build their resilience, may help to alleviate some of the retention and recruitment challenges facing nursing. In addition, taking better care of the nursing workforce has substantial implications in terms of increasing efficiency within healthcare systems and benefitting the quality and safety of patient care. 

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