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.