CPD: Resilience – the essentials for OH nurses

What are some of the factors that affect individual resilience, and how might the ability to bounce back after adversity benefit our roles? Elly Dady looks at how work-related stress can be beneficial for the resilience cycle.

It has been two years since the UK’s first national lockdown, and the need for resilience has been evident for everyone. As well as the enormous work undertaken in relation to Covid, occupational health practitioners may be seeing employees for stress-related conditions or advising managers and the organisation about strategies to reduce stress across the organisation.

Prior to this pandemic, Kinman et al (2020) reviewed 100 studies related to stress in nurses and midwives in a joint paper commissioned by the RCN Foundation and the Society of Occupational Medicine. They concluded that nurses and midwives were at considerable risk of work related stress. They identified that poor mental health was increasing due to high demands on staff and diminishing resources.

I have used my experience both as a registered specialist community public health nurse, senior lecturer and course director of the MA Strategic Clinical Leadership apprenticeship and Darzi Fellowship leadership coach at London South Bank University to identify aspects of this topic which may be helpful to OH practitioners.

Resilience is a vast topic so a comprehensive review is not possible. This article discusses resilience mainly from an individual perspective highlighting how effective leadership can support the psychosocial factors underpinning resilience. It poses questions for the reader to provoke individual reflection which can be applied to their own context.

What is ‘resilience’?

 In essence resilience is the ability to bounce back from adversity (Lawson, 2018 p.14).

Southwick et al (2014, p. 315) provide a concise definition: “resilience can be defined as the ability to regain balance following exposure to an adverse event or events. Resilience is not an end state of being but rather a process of adaptation and growth within a risky landscape”.

It is not to say that resilience is the panacea for all, or that a dip in resilience should be used as “a stick to beat” the individuals suffering the effects of stress, but rather one aspect of protection needed to navigate the complex world of modern work.

Although this article focuses mainly on the individual, in the organisational context the onus should not be solely placed on the individual’s coping, but a joined up approach which considers both organisational and individual approaches in line with the evidence base for positive outcomes (La Montagne et al, 2007). As OH professionals we need to be aware of the need to take a systems approach when considering resilience. It is all too easy to focus on the deficit and effects of stress rather than looking ‘up stream’ to see if the organisation can reduce its effects at source and enhance an individual’s resilience through effective leadership and organisational interventions.

There are genetic differences in the way we handle stress, how we interact with our environment and our biochemical reactions. We also know however that genes don’t provide a convenient explanation for the resilience of the individual, although more recent research identifies specific genes (Pleuss, 2016), we know that resilience is largely determined by non-inherited factors. Therefore one’s ability to build resilience isn’t set in stone but rather a complex interaction of neurobiological factors, developmental factors and psychosocial factors (Southwick et al, 2014). More recently advances in brain imaging make it more possible to study the pathways of resilience and increase the depth of our understanding (Southwick et al 2014; Seligman, 2016).

The resilience cycle

Reflection is part of professional practice, in nursing the Nursing and Midwifery Council (NMC) incorporates reflection within the revalidation process (Nursing and Midwifery Council, 2018). Having an understanding of one’s own resilience is important both personally and professionally.

Understanding that resilience is not static, is different for different individuals, changes over time, day to day, depending on our circumstances adds to the complexity of the concept (Southwick et al 2014). There is a need to monitor it frequently as well as to understand that colleagues in the same workplace may be affected by different types of adversity at different times. Equally a colleague who seems to coping at work may be failing to adapt in their personal life.

Patterson and Kelleher (2005) describe the resilience cycle and provide a useful framework in which to map our own resilience. Although this depiction seems linear, it is viewed rather as a structure for individuals to understand the different stages of resilience when adversity strikes. They describe an initial deterioration phase, followed by an adapting phase, leading to the recovery phase, and in some, a growing phase which starts to consider the idea of thriving.

Neville (2022, p.6) highlights comments made by chief nurse Flo Panel-Coates at University College London Hospitals NHS Trust in a recent interview: “the trust had worked hard to accommodate staff who sought a break so that they don’t leave the profession”. However, she also highlighted the number who were redeployed to critical care at the height of the crisis and had elected to remain: a phenomenon she dubbed “post-traumatic growth”.

The concept of “thriving” refers to a person’s ability to go beyond their original level of functioning and to grow and function despite repeated exposure to stressful experiences (Ledesma, 2014), so it is possible grow from adverse events. This may be because we have been forced to learn new skills to deal with upcoming adversity, we have renewed confidence as a result, we gain a sense of self mastery, and /or that we have developed stronger relationships as the result of the adversity and these give us a sense of security moving forward (Carver, 1998).

A discussion on thriving is not in any way meant to take away the threat that psychological hazards pose to the individual. It is heartbreaking to discover that suicides amongst US military staff after the mission to Afghanistan already exceed the number killed in combat (Diez, 2013 cited by Macedo et al, 2014).

Patterson and Kelleher (2005) hypothesise that there are three fuel sources that predict resilience; personal values, personal efficacy and personal energy. As the individual grows from adversity these fuel sources are heightened enabling the individual to face future challenges. This further develops the idea that we can enhance our skills and exercise them, keeping them in our “back pocket” (Judge, 2016) for future adversity.

The researchers themselves suggest that even the most resilient people will feel this ‘rollercoaster effect’ as they deal with adversity (Ledesma, 2014). However, understanding the process of thriving is important especially for leaders who can have an influence on an individual’s psychosocial environment. Leaders can “develop such interventions with an eye towards enhancing health and wellbeing rather than simply promoting a return to baseline of the status quo” (Ickovics and Parks, 1998 cited by Ledesma, p. 4).

Psychosocial factors promoting resilience

In my work at LSBU I have found that some students start with the view that they should try not to bring emotion into work. However as social animals (Lawson, 2018) we know that the workplace forms a very important part of our psychosocial environment and bridges our psychological needs with the opportunities it provides for employment (Marmot et al, 2005). Relationships are very important. Marmot et al (2005, p.100) define the psychosocial work environment in relation to health as: “the interaction between a person’s cognitions, emotions and behaviours and the material social context”. They go onto say that “health and wellbeing to a considerable extent is influenced by the quality and the intensity of these processes” (p.101).

As OH practitioners we will be aware of the legislation that support the reduction of risk in organisations to psychological hazards namely the Management of Health and Safety at Work Regulations (1999). The Health and Safety Executive (HSE) provides detailed guidance in the Management Standards (HSE, 2008) related to the psychosocial environment specifically around demand, control, support, relationships, role and change. This has been discussed in previous articles and will not be discussed further here, however this provides a useful framework which should be reviewed frequently.

Marmot et al (2005) emphasises two motivations in relation to the psychosocial environment, the “need for physical and mental wellbeing as a requirement for an organism’s reproduction and an individual’s productivity” (p.101). In addition there is a need for us to have a positive experience of self. This means establishing an environment which provides opportunities for “belonging, acting or contributing and of receiving favourable feedback”(p. 101).

Marmot (2004) cites Bandura (1986) and continues to highlight two further aspects of positive self-experience and these include self-efficacy, “the belief a person has in his or her ability to accomplish a task” (Marmot 2004, p101) and self-esteem – “the continued positive experience of a persons’ self-worth” (Marmot, 2004, p101).

Looking at the psychosocial environment and our need for self-esteem and self-efficacy we can start to see the role leaders and individuals play in establishing a healthy psychosocial environment not just as “an optional add-on” but as part of fulfilling basic human need. Certainly the giving and receiving feedback then takes on a more significant role when considered in this context.

Psychosocial skills

Although it isn’t known if individual psychosocial factors promote resilience or simply have an association with it, there are a number of psychosocial factors which support resilience in the literature and are summarised by Southwick et al (2017). These include: facing our fears, an ability to regulate our emotions, having a moral compass, a sense of optimism and positive emotions, detailed focus on skills development, altruism, attention to physical fitness, a strong social network, cognitive flexibility, an ability to reframe adversity in a more positive light, commitment to a mission or cause that is meaningful and highly valued. I discuss some of these below.

Mission and unity of purpose

Southwick et al (2017) discuss the importance of mission and a clear sense of purpose for resilient leadership. People with a clear sense of purpose can have a strong resilience which enables them to cope with a large degree of adversity (Lawson, 2018) so as leaders and individual practitioners it is important to be clear about what this is and to ensure that we are united in that mission. As we saw in the first national lockdown in March 2020, we all rallied around a common cause “stay home, protect the NHS, save lives”.

Malby and Huffnett (2020) identify the positive (and negative) effects seen as a result of the changes the pandemic brought in the NHS interviewing a number of frontline staff: “There has definitely been more collaboration across boundaries and I would go as far as to say in many cases the boundaries have come down completely. It feels that everyone is working towards a common purpose and far less working in silos.”

Moral compass and altruism

 Resilient leaders stick to a set of strong moral principles which guide them in times of adversity (Southwick et al 2017) and these are strengthened for OH nurses, as an example in the Nursing and Midwifery Council Code (2018), highlighted earlier in Patterson and Kelleher’s model.

Layard (2016) comments that resilience can be strengthened through “doing good” and making a difference to others. Southwick et al (2017) found that a strong sense of right and wrong strengthens resilience in times of adversity. In addition altruism and concern for other’s welfare was also sewn into their approach.

This might form a deeper understanding of the psychological damage that can occur when individuals are forced to make decisions which contradict their moral code. Certainly this was borne out in my own (unpublished, 2017) research amongst a small group of OH nurses working for OH providers. They described moral distress when they were unable to provide the service they felt appropriate or were prevented from being a “good nurse” as they saw it. Certainly working with colleagues that share one’s own ethical position can be beneficial (Lawson, 2018).

Moral injury is a term that perhaps many of us had not heard of prior to this pandemic. The term arose from work carried out by the armed forces and can be thought of as “psychological distress that results from actions, or the lack of them, which violate someone’s moral or ethical code” (Greenberg, 2020, p.3).

A strong social network

Creating a strong social network seems to be the ‘golden’ thread that is sewn through much of the resilience literature. Van der Kolk (2014) states that “numerous studies of disaster response around the world have shown that social support is the most powerful protection against being overwhelmed by stress and trauma”.

He goes on to make the point that social support is not just being with others but “being truly heard and seen by the people around us” (p.79). He says it is a “biological necessity, not an option” (p.167).

The British Psychological Society (2020) highlight the role leaders can play in establishing strong social networks and systems to support resilience in the workplace. Equally it’s important that as individuals we recognise the part we play in the culture of the organisation and our immediate work environment.

Ability to reframe adversity in a more positive light

The term “hardiness” is synonymous with thriving but it develops the idea that some individuals have the ability to make the best of difficult situations (Ledesma, 2014). Ledesma refers to Bonanno (2004) who identifies these characteristics as: finding a purposeful meaning to life; a belief that we can influence our environment and the outcome of events; and the idea we can grow from both positive and negative life experiences. In practice this means that hardy individuals are able to frame adversity as less threatening which therefore minimises their distress (Ledesma, 2014). Obviously leaders have a role in influencing how situations are framed but as individuals we also have the power to influence this.

A psychologist at UCLH commented recently: “Our teamwork was such that more people survived in our intensive care unit than people died, and you’re there witnessing the people coming through and you’re there talking to the families (Neville, 2022).

Attention to physical and mental fitness

This is well known to be helpful when dealing with stress and perhaps also makes us feel physically stronger to deal with the increased physical and emotional demands that are placed on us at times of adversity, providing benefits to our mental health, mood and cognition. The chemicals released during exercise (endorphins, serotonin, dopamine) improve mood.

Challenging your brain seems also to have been identified as supporting resilience and this of course links clearly to skills development. But no resilience discussion would be complete without the mentioning self-care which as well as exercise include adequate sleep, and a balanced diet (Wei et al, 2019).

Conclusion

Resilience is a huge topic. The focus of this article is on psychosocial factors and the development of resilience to be considered in the context of the OH practitioner.

We know that the psychosocial environment and factors associated with resilience can support individual resilience and reflection has been encouraged around these factors.

As OH professionals we need to examine our own resilience in relation to leadership, our individual skills and knowledge, confidence and the relationships we create at work.

OH practitioners will be using their resilience skills and knowledge not only for themselves but in their interactions with managers supporting them to develop a healthy psychosocial environment for themselves and staff.

I leave you with Yehuda’s (2014, p3) thoughts on resilience, who considers it as an active process involving a “reintegration of self that includes a conscious effort to move forward in an insightful integrated positive manner as a result of lessons learned from an adverse experience”.

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