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.