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\begin{document}

\title{Multiple meanings of resilience: Health professionals' experiences of a
dual element training intervention designed to help them prepare for
coping with error.}



\author[1]{Gillian Janes}%
\author[2]{Reema Harrison}%
\author[3]{Judith Johnson}%
\author[3]{Ruth Simms-Ellis}%
\author[4]{Tom Mills}%
\author[3]{Rebecca Lawton}%
\affil[1]{Manchester Metropolitan University}%
\affil[2]{University of New South Wales}%
\affil[3]{University of Leeds}%
\affil[4]{University of York}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Rationale, aims and objectives: Consistent data demonstrates negative
psychological effects of caregiving on front-line health professionals.
Evidence that psychological resilience factors can help minimise
distress and the potential for low-cost interventions have created
interest in resilience-based development programmes; yet evidence of
perceived value amongst health professionals is lacking. This study
explored health professionals' experiences and perceptions of a novel,
resilience-based intervention designed to pro-actively prepare staff for
coping with error; to investigate their perceptions of what resilience
meant to them, the relevance of the intervention, and impact of
participation on ability to cope with error. Method: Semi-structured
interviews 4-6 weeks post intervention with 23 randomly selected
participants from seven cohorts (midwives, paediatricians,
obstetrians/gynaecologists, paramedics) and trainees (physician
associates, mammographers, sonographers). Thematic analysis of interview
data. Findings: Participants reported various interpretations of, and a
shift in perception regarding what the concept of psychological
resilience meant to them and their practice. These included for example,
resilience as a positive or negative concept and their awareness and
response to a range of personal, organisational and system factors
influencing personal resilience. They valued the prophylactic,
clinically relevant, interactive and applied nature of the intervention;
having developed and applied valuable skills beyond the context of
involvement in error, noting that individuals needed to be willing to
explore their own coping mechanisms and human fallibility to gain
maximum benefit. There was also consensus that whilst proactively
developing individual level psychological resilience is important, so
too is addressing the organisational and system factors that affect
staff resilience which are outside individual staff control. Conclusion:
Enhancing resilience appears to be considered useful in supporting staff
to prepare for coping with error and the wider emotional burden of
clinical work, but such interventions require integration into wider
system approaches to reduce the burden of clinical work for health
professionals.%
\end{abstract}%



\sloppy


\textbf{Title Page}

\textbf{Multiple meanings of resilience: Health professionals'
experiences of a dual element training intervention designed to help
them prepare for coping with error.}

\textbf{Short title:} Preparing health professionals to cope with error

\textbf{Authors: Gillian Janes} 11Manchester Metropolitan
University\textbf{,} Bradford Teaching Hospitals NHS Foundation Trust,
UK; \textbf{Reema Harrison,} University of New South Wales, Australia;
\textbf{Judith Johnson,} University of Leeds, UK;\textbf{Ruth
Simms-Ellis} , University of Leeds, UK; \textbf{Tom Mills,}Bradford
Teaching Hospitals NHS Foundation Trust, UK22University of York;
\textbf{Rebecca Lawton,} University of Leeds, UK.

\textbf{Corresponding author:} Gillian Janes 33Department of Nursing,
Faculty of Health, Psychology and Social Care, Manchester Metropolitan
University, Brooks Building, 53 Bonsall Street, Manchester, M15 6GX, UK

Email: g.janes@mmu.ac.uk Tel: 07745351412

\textbf{Abstract}

\textbf{Rationale, aims and objectives:} Consistent data demonstrates
negative psychological effects of caregiving on front-line health
professionals. Evidence that psychological resilience factors can help
minimise distress and the potential for low-cost interventions have
created interest in resilience-based development programmes; yet
evidence of perceived value amongst health professionals is lacking.
This study explored health professionals' experiences and perceptions of
a novel, resilience-based intervention designed to pro-actively prepare
staff for coping with error; to investigate their perceptions of what
resilience meant to them, the relevance of the intervention, and impact
of participation on ability to cope with error.

\textbf{Method:} Semi-structured interviews 4-6 weeks post intervention
with 23 randomly selected participants from seven cohorts (midwives,
paediatricians, obstetrians/gynaecologists, paramedics) and trainees
(physician associates, mammographers, sonographers). Thematic analysis
of interview data.

\textbf{Findings:} Participants reported various interpretations of, and
a shift in perception regarding what the concept of psychological
resilience meant to them and their practice. These included for example,
resilience as a positive or negative concept and their awareness and
response to a range of personal, organisational and system factors
influencing personal resilience. They valued the prophylactic,
clinically relevant, interactive and applied nature of the intervention;
having developed and applied valuable skills beyond the context of
involvement in error, noting that individuals needed to be willing to
explore their own coping mechanisms and human fallibility to gain
maximum benefit. There was also consensus that whilst proactively
developing individual level psychological resilience is important, so
too is addressing the organisational and system factors that affect
staff resilience which are outside individual staff control.

\textbf{Conclusion:} Enhancing resilience appears to be considered
useful in supporting staff to prepare for coping with error and the
wider emotional burden of clinical work, but such interventions require
integration into wider system approaches to reduce the burden of
clinical work for health professionals.

\textbf{Keywords:} Resilience, healthcare professionals, error, coping
intervention

\textbf{Data availability statement:} Data is available on request due
to privacy/ethical restrictions.

\textbf{Conflict of interest statement:} The authors have no conflict of
interest to declare.

\textbf{MAIN TEXT}

\textbf{Introduction}

Health systems internationally face significant and escalating
challenges to provide care that offers both value and quality in the
context of rising costs of care, aging populations, complex conditions
and comorbidities.(1, 2) Healthcare professionals at the clinical
front-line have borne much of the burden, evident in consistent data
demonstrating high levels of stress and burnout(3-5), while studies have
shown consistent links between these negative psychological effects and
healthcare safety and quality. (6-8) Strong evidence that psychological
resilience factors can help minimise distress, coupled with the
potential for low-cost opportunities to intervene, have given rise to
interest in the development and application of resilience-based
interventions to address psychological distress amongst health
professionals.(6, 7) Resilience factors are those which statistically
moderate the association between exposure to stressors and negative
outcomes; those who have high levels of resilience are less likely to
show negative reactions in the face of stress.(6) Resilience-based
interventions therefore seek to develop individuals' capacity to
maintain emotional equilibrium in response to difficult experiences.(8)

Resilience-based interventions have faced substantial criticism as the
wrong solution to address system inadequacies that create occupational
suffering.(9) The misapplication of resilience-based interventions in an
attempt to build capacity for enduring pervasive health system stress
has led to such interventions being criticised for masking inherent
system and organisational failings. For example, the application of
resilience training in the UK health system, to enhance health
professionals' capacity for ``absorbing any unacceptably and avoidably
negative conditions'', has created distaste for the implementation of
such training.(10) The potential value of resilience-based training in
enabling healthcare professionals to prepare for burdens associated with
clinical work is supported, but it is critical for such training to be
applied only in the context of systematic solutions to tackle the burden
on health professionals that is created by system inadequacies.(9, 10)

Since the late 1990s the impact of involvement in medical error for
healthcare staff and associated psychological distress which often
heightens potential for further unsafe care has gained increasing
attention.(11) Despite extensive focus, few interventional approaches
have been developed and fewer have been comprehensively evaluated for
their effectiveness in addressing psychological distress.(12-14) To
date, interventional approaches have been limited to programs that
integrate a range of approaches to support healthcare staff following an
error. However, despite a burgeoning commentary in the literature
regarding the topic of resilience, we are unaware of any studies that
have directly explored healthcare professionals' views of the concept of
`resilience' following participation in resilience-based training
interventions. Furthermore, there is little evidence of the experience
of health professionals who undertake resilience-based programs
regarding their acceptability and value.

A novel, prophylactic, resilience-based coaching intervention was
developed by the authorship team to prepare healthcare professionals to
mitigate the negative impacts of involvement in making an error. The
intervention was evaluated using a mixed-methods design. The findings,
which are published elsewhere, demonstrated that the intervention
significantly increased resilience levels, confidence in coping with
error and knowledge of resilience building strategies and their
application amongst 66 health professionals in the UK from diverse
professions. (15) The intervention comprised a 3.5 hour interactive,
group workshop involving 4-12 participants and a follow up one hour 1:1
coaching phone-call with a facilitator that enabled participants to
explore issues they did not feel comfortable discussing in a group
setting and their application of the learning in practice. The workshop
was theoretically underpinned by an evidence-based concept of resilience
to failure events and drew on cognitive-behavioural therapy principles
(16) to enable participants to identify and use evidence-based
techniques for developing relevant traits and abilities.(7) Work-based
case studies, tailored to stressful aspects of clinical practice and
errors commonly experienced by the specific discipline groups, were used
to facilitate learning and enhance perceived relevance. The facilitators
were a Clinical Psychologist (JJ) and an Occupational Health
Psychologist (RSE) with experience in CBT-based interventions. Eligible
health professionals were employed in the target disciplines of
midwives, doctors, paramedics, or completing an education programme
leading to qualification as physician associates, sonographers or
mammographers. Healthcare staff were invited to participate in the
intervention via their employing organisations (qualified healthcare
professionals) or programme leads (trainee healthcare professionals).

A qualitative evaluation conducted alongside the intervention answered
the following research questions, designed to glean the knowledge
required to optimise future implementation approaches:

\begin{itemize}
\tightlist
\item
  how is the concept of psychological resilience perceived by healthcare
  professionals within the context of healthcare practice?
\item
  how do healthcare professionals perceive and respond to the novel
  intervention being tested?
\item
  how relevant do participants perceive the intervention to be for them
  and their roles?
\item
  how do participants perceive their ability to cope with error?
\end{itemize}

\textbf{Methods}

\textbf{Ethical approval}

All participants provided informed consent prior to participation. The
study was approved by the University of Leeds, School of Psychology
Ethics Committee (PSC-509/29 November 2019) and NHS (REC reference
19/HRA/0391).

\textbf{Design}

Descriptive, qualitative interview study.

\textbf{Recruitment}

A random number generator was used to select a minimum of four
individuals from each uni-disciplinary cohort to ensure all disciplines
were included. This provided a target sample of 32 from the 66 staff who
had participated in the intervention. These individuals were invited to
take part in the qualitative interviews and recruitment ceased once the
data gleaned from the sample was deemed to provide sufficient
`information power'.(17)

\textbf{Data collection}

One-to-one, audio-recorded, telephone interviews of 30-45 minutes were
completed with participants 4-6 weeks post workshop and transcribed
verbatim. GJ and TM conducted the interviews from a private room on NHS
premises and at a pre-arranged time to enable participants to be in a
private location of their choice. A semi-structured interview guide was
used (see Appendix). This was broadly structured around perceptions and
experiences of the two elements of the intervention; the training
workshop and follow up coaching phone-call. Questions focused on the
personal impact of the intervention on participants and their
practice/personal development. Data emerging from additional questions
regarding the logistical aspects of the intervention, such as its format
and design, are reported elsewhere with the quantitative intervention
outcomes.(15)

\textbf{Data analysis}

Interview transcripts were analysed by two researchers (GJ; RH) using a
reflexive, inductive thematic analysis approach (18) to identify
`semantic' (i.e. surface, explicit) and `latent' (i.e. implicit or
underlying) themes.(19) Repeated listening to the audio recordings
enabled initial familiarisation with the data then each researcher
independently conducted line-by-line coding, identified key words,
phrases and sentences (20) and used these to identify data driven themes
(21). Coding was iterative and refinement of themes and subthemes
evolved inductively over the course of the analysis.(22) A team-based
approach to coding was used(19) in which discrepancies were discussed
and themes and subthemes refined until shared understanding and
agreement was reached. (23) Measures used to assure the trustworthiness
of the analytic process included discussion between the two researchers
to facilitate constant comparison, refining and defining themes and
categories (24, 25), until a point of theoretical saturation. A third
researcher (JJ) then assessed the themes for face validity. The
contribution of the wider research team in coding and categorisation
checks, and discussion regarding the influence of the research context,
ensured the credibility, confirmability and dependability of the
analytic process (26).

\textbf{Findings}

We conducted interviews with 23 health professionals (18 female) who
participated in the intervention. Participants included: paediatric
consultant doctors (4), trainee paediatric doctors (4), physician
associate students (4), midwives (4), sonography or mammography students
(3), paramedics (3), trainee obstetrics and gynaecological doctor (1).

Participants generally found the intervention to be highly valued and
worthwhile. Four data derived themes were identified:

1. shifting perspectives on resilience

2. humanising clinical work

3. resilience as pervasive across personal and professional life

4. resilience building as personal development

along with one over-arching theme:

5. resilience as contextual and multi-layered

\textbf{Shifting perspectives on resilience}

This theme reflects the mixed and complex feelings and attitudes
participants held about the concept of resilience and how this had
altered as a result of engaging with the intervention. Participants
generally reported that resilience was a common but poorly understood
term that was used differently across the health system, and
specifically within the NHS. Allied Health Professionals in particular
reported that whilst resilience was viewed primarily as a nursing issue
it was becoming more widely acknowledged in their disciplines.
Participants across all staff groups reported that generally, resilience
training was perceived negatively. They attributed this to widespread
misunderstanding of the term and previous experiences of training that
was branded as resilience, but focused on individuals' behaviour without
recognising and addressing relevant system level issues:

\emph{``\ldots{}resilience is a way of putting it onto the individual
without changing systems''} (4727R Paediatrics doctor).

Participants recognised a dissonance between the provision of resilience
training and their experience at work which further reinforced this
perception:

\emph{``\ldots{}it's a {[}NHS{]} cultural thing\ldots{} it feels very
oppressive and dictatorial\ldots{}unsupportive\ldots{}incidents are not
dealt with very well\ldots{}we've lost supervision\ldots{} which has had
a huge effect on\ldots{}where we can go {[}for{]} support\ldots{}in the
profession so\ldots{}doing something like this\ldots{}does
feel\ldots{}temporary because when you're going to work every day and
you're still battered with rubbish and poor staffing\ldots{}it doesn't
take long for you to slip back\ldots{}and not use the\ldots{}strategies
and that's a bit sad, having said that\ldots{}our management must've
ok'd\ldots{}this training\ldots{} so there must be\ldots{}awareness
there\ldots{}doesn't marry up with how on a shop floor level it
works'}(3227M Midwife Y cohort)

The inadequacy of previous approaches to resilience development was
identified as a long-standing issue. For example, participants reported
previous resilience training as having focused on the legal issues
associated with error, which had actually generated fear in those taking
part. One participant noted this intervention was the first useful
resilience training they had had in 11years:

\emph{``it was practically useful not just `go and do yoga''
(4727R}Paediatrics doctor\emph{)}

Many welcomed the proactive, practical nature of the intervention, but
emphasised it would be important to advertise it as `preparation for
coping with error' rather than `resilience training' in order to engage
health professionals and overcome the negative legacy associated with
resilience training.

Overall, staff reported that the intervention filled a `huge gap' that
had become even more important given the increasing pressures under
which they were now working. They associated these pressures with for
example increasingly complex patient care, increased expectations and
greater risk of litigation. Whilst some interviewees already had a good
understanding of resilience and found the intervention reinforced their
current practice, most had developed a new understanding as a result:

\emph{``I have a better understanding than beforehand\ldots{}I would've
said that I was fairly resilient kind of person anyway\ldots{}But it's
always good to {[}brief pause{]} to kind of talk about how you would
deal with something in a in a different context especially at work so
that that's been useful.''} (7701I Physician Associate).

This encompassed greater awareness of factors that were largely outside
the control of the individual, which provided a revelation for some with
a previous tendency to self-blame:

\emph{``\ldots{}big learning curve for me\ldots{}it's shown me how I do
deal with\ldots{}.actually how I don't\ldots{}.how potentially
un-resilient\ldots{}I suppose destructive I've been to
myself\ldots{}.definitely an eye-opener.'' (3208S Midwife B cohort).}

\textbf{Humanising clinical work}

The unifying and humanising impact of the intervention was evident
throughout the interviews. Participants highlighted the inevitability of
error and emotional burden inherent in clinical work but reported that
these were rarely discussed issues. The intervention helped them build
resilience and they appreciated the opportunity to normalise and
legitimise their own experiences. This experience of the intervention
led to commentary around broader applications of the resilience-based
intervention beyond error. Participants commented on being acutely aware
of the inherent challenges and risks associated with clinical work; both
in terms of the nature of the work itself:

\emph{``children aren't going to stop dying, next week they are going to
be dying so how do we deal with that.'' (4727A Paediatrics doctor)}

and the increasing risk associated with the changing nature of that
work:

\emph{``\ldots{} really difficult because of there's such high risk
women these days and the complexities\ldots{} are definitely different
so I think to get through your working life\ldots{} unscathed is a
miracle.''(3208S Midwife B cohort)}

There was also recognition that the emotional burden was pervasive
rather than specific to a small number of individuals:

\emph{``\ldots{} all of us can be subjected to at any time.. that's
given\ldots{}you're out there for any of that\ldots{}You're held
accountable regardless\ldots{}even if we don't work in a blame culture
we as health professionals we blame ourselves\ldots{}that can be very
destroying erm so it's about trying to\ldots{}help yourself and others
cope with those feelings to sort of turn that around\ldots{}we do
self-blame\ldots{}that's the nature of the healthcare
profession\ldots{}there's erm a lot at stake isn't there\ldots{}
so\ldots{}you tend to go out there and\ldots{} something happens or you
miss something you blame yourself for it\ldots{}There's something I
should've done or could've done.'' (6013B Midwife Y cohort)}

Whilst this experience was common, there was also a new sense of this
negative internal dialogue as being unwarranted: \emph{``\ldots{}know
nobody chooses to make a mistake.'' (6608N PA} ). Interviewees also
reported that participating in the intervention had legitimised their
own experience of error as others had voiced similar impact, resulting
in loss of confidence or ``\emph{losing your nerve''} (6013B Midwife Y
cohort).

One participant summed up the views of many in describing the
intervention as:

\emph{``\ldots{}very freeing\ldots{}allowing you to feel that what we do
isn't normal\ldots{}.that some days you just need to go home and have
pizza and gin and that's ok '' (4727A Paediatrics doctor),}

Participants also described acting as \emph{``a stress sponge''} (8421R
Paramedic) for their peers. For example, they reported having supporting
colleagues to their own detriment, and worried about the impact of
clinical work on new entrants, particularly younger colleagues or those
with limited life experiences to draw on.

\textbf{Resilience as pervasive across personal and professional life}

The pervasive nature of personal resilience and how it impacted on
aspects of both work and personal life was discussed by several
participants who reported that the application of learning from the
training was a `virtuous circle' spanning every aspect of their lives:

\emph{``It's got wider benefits\ldots{}if you can become more resilient
or learning techniques\ldots{}.that's going to rub off into your day to
day life, not just the job.'' (0606Y Paramedic})

Interviewees also noted everyday relevance at work that was not just
limited to error experiences:

\emph{``\ldots{}adverse incidents was the main issue but actually all
the case studies\ldots{}that we went through is actually my working life
every day.'' (3208S Midwife B cohort)}

Thus, using case studies that were relevant to everyday clinical
practice and activities requiring personal application of learning
helped participants to take a broader view, promoting a more balanced
approach to their own experiences.

Many interviewees discussed `paying forward' their learning from
participating in the intervention by using it to support others,
recounting a range of examples of where this had already happened. This
indicates the value staff placed on the learning and the wider impact of
their participation. However, developing and maintaining resilience was
an ongoing process. In particular, participants reported that it takes
time to develop new habits and ways of thinking:

\emph{``\ldots{}it does take time, it's little steps at a time\ldots{}my
colleague\ldots{}we're always\ldots{}chatting and debriefing
everything\ldots{}sharing with each other so she's\ldots{}my go to
person at work (3208S Midwife B cohort)}

As this participant highlights, the importance of ongoing support was
key for maintaining the benefits of participation in the intervention.

\textbf{Resilience building as personal development}

The degree to which participants saw resilience building as an integral
part of their personal development as a health professional varied. The
personal challenges involved in engaging in self-reflection and
development work to enhance personal resilience were frequently
identified and individuals' readiness to engage with this type of
intervention appeared to influence their responses. Participants
commented on their own readiness to engage in personal development in
terms of resilience building, but also that of colleagues.

Although without exception, participants thought the intervention should
be available to all healthcare professionals, there was also recognition
that individuals needed to be ready to explore the topic and their own
response to it:

\emph{``I reckon there'd be quite a few people\ldots{}who don't feel
they want to put themselves out there by taking a resilience course.''
(6202M Physician Associate)}

Participants overwhelmingly valued the intervention. Nevertheless, many
noted that self-analysis, however well facilitated, was difficult and
could be associated with avoidance. As a result, there was consensus
that participants needed to be open to exploring the topic for
themselves and therefore the intervention may not suit everyone. Whilst
the workshop setting provided `a place to hide' if necessary, this was
less so for the follow-up, coaching phone-call which, even though valued
by almost all participants, provoked a particularly emotional response
from one which required skilled facilitation. This individual felt very
strongly that probing to identify personal strengths and reflect on
their resilience was too personal and very uncomfortable:

\emph{``I feel uncomfortable with like saying oh `name a positive
characteristic', that's actually a really uncomfortable thing for me to
do.''} (0706I Paediatrics doctor)

Whilst only one participant responded to the follow up call in this way,
others identified avoidance of exploring personal resilience as a
relatively common coping mechanism:

\emph{``A lot of my colleagues spend a lot of time putting a brave face
on things\ldots{}probably not fair\ldots{}they try and push through
things and\ldots{}make light of problems\ldots{}that's the way they've
developed how to cope.'' (8421R Paramedic)}

Participants commonly reported identifying personal strengths as a
particular challenge, with a number noting how unusual it was to be
encouraged to focus on their strengths:

\emph{``\ldots{}I wasn't expecting the time spent to take me through
what my strengths were\ldots{} certainly I found it very
helpful\ldots{}These are things I would never have spent time thinking
about\ldots{}I often spend time thinking about the negative but thinking
about the positive side of it it's been very unusual.''} (8421R
Paramedic)

Almost all participants valued this process, some even found amusing the
probing the facilitator needed to do to enable them to identify their
strengths: ``\ldots{}\emph{it was like pulling teeth!''} (3208S --
midwife B) because this positive approach was so unfamiliar. This type
of probing and exploration of why they might find this type of
reflection difficult, within the `safe' environment of the one-to-one
coaching follow-up call, often resulted in new insight for participants.

Thus, whilst all participants thought the workshop element of the
intervention would be valuable for all staff, views were mixed regarding
the follow up coaching phone-call. A fifth of thought this should be an
optional element of the intervention because it had the potential to
open `pandora's box' by challenging an individual's personal coping
mechanism before they were ready to deal with it.

Participants also felt that the intervention would be most attractive to
staff who recognised the inherent risks associated with clinical
practice, their own human fallibility and valued preparedness or were
seeking personal development to help them develop solutions in response.
Readiness to engage appeared to be influenced by participant perceptions
of whether or not they saw building resilience as part of personal
development. Not all interviewees thought that having previously
experienced involvement in an error should be a pre-requisite for
participating in the intervention, possibly having recognised the
transcendent nature of resilience and wider relevance of the strategies
learned highlighted earlier.

\textbf{Overarching theme: Resilience as contextual and multi-layered}

The contextual and multi-layered nature of resilience was evident
throughout participant responses and featured consistently across all
four of the previous themes. It therefore represents an overarching
theme. Participants perceived resilience and personal resilience
building as a complex concept, which is influenced by the individual and
the organisation they work within. Participants generally viewed
personal resilience as embedded within and therefore influenced by the
health system and service. For example, as illustrated in theme 1,
participant perspectives on resilience were shaped by the immediate and
wider work systems contexts in which they worked, for example resilience
was perceived primarily as a nursing issue by some disciplines and
previous resilience training as a negative experience, which affected
the way they initially engaged with the intervention.

Participants identified three discreet but inter-connected contexts as
influencing personal resilience, each related to the degree of control
individual staff had over them. Two of these: the inherently risky
nature of clinical work and factors at organisation and system level,
were largely outside individual control; whilst the third, personal
factors, were more within the individual's locus of control. For
example, theme (2) `humanising clinical work' involved recognition that
the very nature of clinical work, whether associated with recognised
sentinel events such as an error or not, involved inherent risk.
However, what ultimately affects the potential impact of this on staff,
for example, organisational processes such as incident investigation and
organisational and professional cultures regarding error, were largely
outside the control of the individual. In contrast, coping and
resilience-building strategies such as prioritising self-care and
accessing support were also recognised as important and could be used
for positive coping as they were more within the control of the
individual health professional. However, participants did not view these
individual-level strategies as sufficient in themselves to mitigate the
impact of the wider system factors identified. Thus these three broad
contexts, and the degree of control they afforded individuals, were
integral to all four sub-themes in terms of how participants framed
their responses.

\textbf{Discussion:}

In evaluating participant experiences and perspectives relating to a
novel resilience-based coaching intervention to reduce the negative
impact of error on healthcare professionals, we established new
knowledge of the potential value of resilience-based interventions and
their applications. Participants universally agreed that this
resilience-based coaching intervention filled a serious, longstanding
gap in staff training (27, 28). Its focus on acknowledging human
fallibility and the broader influences on staff resilience, whilst
enabling participants to develop effective coping strategies,
represented the type of development staff needed to help mitigate the
impact of the psychological distress resulting from clinical practice.
This finding is consistent with recent criticisms of previous resilience
training which has predominantly focused on individual coping versus
system change, leading to negative perceptions of resilience
training.(9, 10) To our knowledge, this was also the first study to
directly explore healthcare professionals' views on the concept of
resilience. As the findings indicate, these were influenced by a range
of individual, organisational and professional level factors such that
the impact of a single, individual level intervention, within a complex
system like healthcare, will always be limited. Thus, our findings add
new knowledge in support of recent calls for greater focus on the need
for system-level interventions and outcome evaluations alongside those
at individual staff level.(12, 13)

The uniqueness of this intervention was its focus on prophylactic
preparation for coping with error and the use of practical, evidence
based self-management and support strategies. This novel focus was
highly valued by participants and is to our knowledge the first
intervention of this nature to be tested. We therefore suggest that
these are not only important features of a resilience-based programme
but, when emphasised as features of an intervention, they are also
likely to promote health professional engagement and maximise impact.
Using these findings to inform future resilience-based interventions
would also help address previous policy recommendations that staff views
on the type of training needed to support their wellbeing is taken into
account (29).

Whilst this study found focusing on dealing with error was beneficial,
participants consistently noted that they used the strategies they
developed through the intervention to help them to cope with the wider
emotional burdens of clinical work and personal lives. This potential of
the intervention to enable health professionals to be better equipped to
cope with the wider emotional burden associated with everyday clinical
work suggests it may contribute to staff wellbeing more broadly while
the reported impacts extend further than the participants involved, as
many recounted examples of how they were `paying forward' their learning
by supporting other colleagues in the workplace. This `virtuous circle'
phenomenon may be particularly important given that staffing is
currently recognised as a `make or break' issue for healthcare with
shortages already affecting care quality and staff experience.(27)

The importance of guided reflection and coaching was apparent in
enabling the application of learning and use of evidence-based
strategies to support psychological resilience and wellbeing as a
routine aspect of participants' clinical roles. Some interviewees
however, questioned the feasibility of scaling-up the relatively
resource intensive coaching telephone call element of the intervention.
In addition, a small number of participants found this element of the
intervention personally challenging, for example in requiring them to
identify their strengths or to consider the phenomenon of human
fallibility and the potential of making an error themselves. These
factors could explain the mixed findings regarding whether or not the
coaching component should remain a core element of the intervention or
become optional, even though it was one of the most highly valued
components by many participants. Despite coaching being widely used
outside healthcare (30), its use and evaluation in a healthcare context
is more recent and has focused primarily on supporting the development
of healthcare leaders (31). However, evidence is now emerging that
demonstrates the role of coaching interventions in supporting wellbeing
and reducing burnout in health professionals (32).

Many interviewees noted that this type of resilience-based intervention
would not suit all staff as participants needed to be ready and willing
to explore their own emotional responses to clinical work experiences,
coping mechanisms and human fallibility or potential for error. These
are not issues that healthcare professionals are traditionally taught or
encouraged to focus on however. Our data indicated the tip of a
potential `iceberg' of maladaptation in which some staff use avoidance
techniques to help them manage the psychological challenges of clinical
work. This was an incidental finding that we did not set out to explore,
but may warrant further investigation. Such findings reflect system and
cultural factors, including punitive or accusatory approaches to
incident investigation, whose significance are widely recognised in the
so-called `second victim' literature, see for example (11, 33, 34).

Our findings reinforce those of previous studies which have found that
the inherently risky and demanding nature of clinical work, coupled with
greater patient complexity, can take its toll on clinical staff.(35) The
need for effective interventional approaches at individual and system
levels to support workforce well-being and enhance mental health now and
for the future is clear, as participants expressed concern about the
longer-term impact of the psychological demands associated with clinical
work on the workforce if not more effectively mitigated. This is
particularly relevant in the context of current healthcare workforce
recruitment and retention challenges and the need to retain staff as a
key priority.(27, 28) This makes this exploration of the first
resilience-based coaching intervention to focus specifically on
preparing health professionals to cope with error as an intrinsic
element of healthcare work an important contribution to the current
evidence-base.

\textbf{Recommendations:}

Whilst specialist knowledge and facilitation skills are required by
those delivering a resilience-based coaching programme like this, its
potential as a cost-effective and scalable intervention is great given
the size of the healthcare workforce who could benefit. Scalability is
possible without losing intervention fidelity, using controlled
`manualisation' of the intervention and a `train the trainer' model.
This approach could enable specialist up-skilling of mental health
professionals and other experienced facilitators with transferable
psychological care skills and specialist Cognitive Behavioural Therapy
training to provide a critical mass of appropriately trained and
supported facilitators to enable widespread availability of the
intervention.

The wider applications of resilience-based coaching interventions such
as the one explored here also offer great potential as a relatively
low-cost, scalable means of supporting the general well-being,
psychological resilience and coping mechanisms of health professionals
dealing with the inherent, non-error related challenges of their
everyday work.

Health systems and organisations seeking to garner the gains of
resilience-based programmes must first address negative connotations
associated with such interventions by distinguishing the role of
resilience in the context of system inadequacies. Despite evidence of
resilience-based interventions working to support health professionals
in managing clinical work, the reluctance of some staff to engage with
resilience training due to its misapplication in many healthcare
contexts, prohibits effective implementation. Future resilience-based
interventions should therefore take account of previous critiques
regarding individual versus system change and focus on the prophylactic
application of practical, evidence based self-management and support
strategies of relevance to specific aspects of clinical working, which
are highly valued by staff, if they are to maximise staff engagement and
impact in practice. Most importantly, to be truly effective, developing
staff capability around resilience requires more than just delivering
training, but must also involve system change. Examples should include
changes to the current predominantly individual focus of
resilience-based intervention design and incident investigation that are
largely outside the control of individual health professionals.

\textbf{Limitations/strengths}

The inclusion of a range of professional groups, both qualified and
in-training and the relatively open nature of the interviews are
strengths of the study that enabled participant perspectives to take
prominence. In addition, the strategies taken to ensure robust study
quality enhance the trustworthiness of the findings. The descriptive
nature and qualitative design mean the study is not, nor did it set out
to be, generalisable to the entire healthcare population or disciplines
involved. The findings do nevertheless provide potentially transferable
learning for other similar contexts and staff groups. They will also
inform wider empirical testing of the intervention.

\textbf{Conclusion}

As the first of its kind, designed to enhance healthcare staff
preparedness for error, this intervention effectively addressed a
crucial, longstanding gap in healthcare staff development. In line with
previous studies, the findings indicate that individual resilience is
inextricably linked to health system and service context. Thus, whilst
interventions to develop individual staff resilience are important, they
are not a panacea. The positive outcomes participants attributed to the
intervention tested here will merely be temporary if system and cultural
change regarding the organisational response to error, better
recognition of the need to design systems to take account of human
fallibility and the emotional impact of clinical work is not
forthcoming.

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\textbf{Acknowledgements}

\emph{This research was funded by the National Institute for Health
Research (NIHR) Yorkshire and Humber Patient Safety Translational
Research Centre (NIHR YH PSTRC). The views expressed in this article are
those of the author(s) and not necessarily those of the NHS, the NIHR,
or the Department of Health and Social Care.}

\textbf{Conflict of interest statement for all authors}

The authors have no conflict of interest to declare.

\textbf{Appendix} : Promoting psychological resilience in the health
professions: Interview Topic Guide

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