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
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:
“…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:
“…it’s a [NHS] cultural thing… it feels very oppressive and dictatorial…unsupportive…incidents are not dealt with very well…we’ve lost supervision… which has had a huge effect on…where we can go [for] support…in the profession so…doing something like this…does feel…temporary because when you’re going to work every day and you’re still battered with rubbish and poor staffing…it doesn’t take long for you to slip back…and not use the…strategies and that’s a bit sad, having said that…our management must’ve ok’d…this training… so there must be…awareness there…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:
“it was practically useful not just ‘go and do yoga” (4727RPaediatrics doctor)
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:
“I have a better understanding than beforehand…I would’ve said that I was fairly resilient kind of person anyway…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:
“…big learning curve for me…it’s shown me how I do deal with….actually how I don’t….how potentially un-resilient…I suppose destructive I’ve been to myself….definitely an eye-opener.” (3208S Midwife B cohort).
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:
“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:
“… really difficult because of there’s such high risk women these days and the complexities… are definitely different so I think to get through your working life… 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:
“… all of us can be subjected to at any time.. that’s given…you’re out there for any of that…You’re held accountable regardless…even if we don’t work in a blame culture we as health professionals we blame ourselves…that can be very destroying erm so it’s about trying to…help yourself and others cope with those feelings to sort of turn that around…we do self-blame…that’s the nature of the healthcare profession…there’s erm a lot at stake isn’t there… so…you tend to go out there and… something happens or you miss something you blame yourself for it…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: “…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 “losing your nerve” (6013B Midwife Y cohort).
One participant summed up the views of many in describing the intervention as:
“…very freeing…allowing you to feel that what we do isn’t normal….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 “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.
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:
“It’s got wider benefits…if you can become more resilient or learning techniques….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:
“…adverse incidents was the main issue but actually all the case studies…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:
“…it does take time, it’s little steps at a time…my colleague…we’re always…chatting and debriefing everything…sharing with each other so she’s…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.
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:
“I reckon there’d be quite a few people…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:
“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:
“A lot of my colleagues spend a lot of time putting a brave face on things…probably not fair…they try and push through things and…make light of problems…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:
“…I wasn’t expecting the time spent to take me through what my strengths were… certainly I found it very helpful…These are things I would never have spent time thinking about…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: “…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.
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.