Building Resilience in Nurses: The Need for a Multiple Pronged Approach

In the years I have been a nurse I have witnessed and engaged with massive changes in care delivery, preparation for practice and workforce management. All of which have created immense stresses for nurses. In recent times there has been a great deal written about nursing and a significant proportion of what is written focuses on unconstructive aspects such as lack of work-readiness and personcenteredness. In this editorial I will examine health care and its relationship with resilience in nurses.


Editorial
In the years I have been a nurse I have witnessed and engaged with massive changes in care delivery, preparation for practice and workforce management. All of which have created immense stresses for nurses. In recent times there has been a great deal written about nursing and a significant proportion of what is written focuses on unconstructive aspects such as lack of work-readiness and personcenteredness. In this editorial I will examine health care and its relationship with resilience in nurses.
Resilience is a term that we are hearing a lot lately. It is usually associated with the ability to "carry-on regardless" and a person's ability to adjust. However, it is also often considered as a personality trait rather than a strategy that can be learned and utilised. "Resilience is the ability of individuals to bounce back or to cope successfully despite adverse circumstances" [1] though many definitions have often been inconsistent, incomplete and not clearly measurable. Sometimes change is regular and things advance in a fairly constant and expected way. Sometimes, it is rapid, confusing and de-stabilising and tests our adaptive abilities.
Resilience is generally developed in our childhood as we experience the disappointments and anxieties that life presents. Some of us also unfortunately experience greater adversity in our childhoods such as family conflict, parental abuse or neglect and childhood illnesses and trauma. For many, despite these adversities, they are happy functioning adults engaged with family, friends and employment. This is resilience.
A great deal of research has been devoted to identifying the protective factors and processes that might account for children's successful outcomes under high-risk conditions [2,3]. The seven factors that influence resiliency are: using initiative, being creative, having humor, being moral, having insight, building strong relationships, and being independent.
So, if resilience is developed in childhood why should we be so concerned with the concept in nursing? We should be concerned because nurses confront adversities every day that people in the general population do not. It is not just the emotional burden that nurses deal with in their interactions with patients, their families and the trauma that these bring; it is also what nurses witness. Moreover, current health care systems and practices create stressors for nurses and bounce from rapid system changes, distancing of nursing work from direct patient care, to patient load and workplace bullying... and they are getting worse.
Workplace stress is a very common compensated illness world-wide [4] accounting for billions of dollars in estimated direct and indirect costs. Nurses and their colleagues working in the health and community services sector are no exception and make compensation claims for stress-related illnesses at higher rates than workers in other sectors [4]. Something must be done.
Many authors address self-care as a mechanism for dealing with workplace stress [5,6]. McAllister and Lowe, in their book The Resilient Nurse [7], provide ample suggestions for the development of self and include good friendships and loving relationships; rehearsing the expression of feelings honestly; managing responses to negative experiences; and a myriad of other healthful suggestions such as finding a mentor or role model, keeping as physically as well as possible, using humor and reflection.
There are also many recommendations for resilience building to be incorporated onto nursing curricula and a number of universities include reflective practice, mindfulness and peer support programs in their courses. Whilst this is also laudable, what happens after graduation? Individual nurses may help themselves but the system must also help. This is the province of nursing leaders in the health care sector. What can they do to promote resilience?
Resilience based approaches are grounded on a strengths based model, whereby the emphasis is focussed on the factors that promote life success, rather than eliminating the factors that promote failure.
The effect of social support on resilience is widely accepted. Studies have shown that resilient individuals were more likely to have more social support than non-resilient individuals. Moreover, those with high social support were 40% to 60% more resilient than those with low social support. Nursing is a social activity so it provides an excellent opportunity to systematically organise nurses to engender peer-led and mentor-led groups that create "resilience networks".
Despite all individual and collective efforts there will be times when nurses cannot cope and become unwell. They might use substances inappropriately, suffer mental health issues and ultimately leave the profession. What can be done about this? Clearly, referral to treatment services is needed and most health services utilise employee assistance programs, which offer confidential services to all employees and are usually run by psychologists. Despite clinical expertise, these counsellors are generally not nurses and may not understand the specific pressures that nurses endure.
An excellent example of a nurse led program is one that runs in Victoria. Its goal is to provide individual assessment and case management to nurses who are referred to the service for mental health or substance use issues. It is run by nurses for nurses and sits separately from the employee assistance programs offered through employers.
Nurse managers are crucial in dealing with employee stress. This requires having the right people in the job and providing the training and resources to support their nursing staff. Hart et al in an integrative review of resilience in nursing provide suggestions for nursing leaders that range across individual, group and organisational levels [8].
Some of the initiatives that nurse managers can utilise include introducing staff meetings to allow nurses to discuss psychosocial and emotional aspects of caring for patients based on a case study approach. Organisation-wide strategies include: Interdisciplinary effective communication; Effective team building/teamwork; Conflict management and resolution; Stress reduction workshops; Zero Tolerance for disruptive behaviours (bullying/horizontal violence); Personal health incentives such as Smoking cessation classes and Workout/gym facilities [8]. Many studies have found that clinical supervision provides a strong base for managing workplace stress in a safe supported environment [9,10].
Adequate staffing levels and skill mix is also important. Managers must keep an eye on their staffing profile. Whilst ratios exist in some jurisdictions, they are not consistent across all or even across sectors. Nurses at all levels are often required to work outside their scope of practice causing stress and dissatisfaction.
Importantly employees need to feel valued. Not just for their work contribution but on a personal level as well. Nurse managers must also listen to them about their concerns, needs and ideas and offer them a measure of control over their work.
To achieve these outcomes for the nurses they lead, nurses leaders must have the courage to advocate for nurses to policy makers and health service executives; to stick with their convictions about nursing and nurses in the face of opposition. They need an appetite for risk and to tough things out. This means they will make mistakes but will also learn from them. They must embrace diversity and lead with compassion and humility. True leadership for resilience is to develop and model it for those who aspire as excellent nurses [11].
This editorial has touched briefly on the theme of resilience and how both individuals and nurse leaders can build resilience to mitigate the impact of work place stress on nurses.