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.