The importance of teaching and learning resilience in the health disciplines: A critical review of the literature

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Summary

This paper, based on a review of the literature, discusses resilience and the application of resilience research to nursing education. The paper advances the educational discourse on professional preparation, arguing that resilience theory should be part of the educational content and taught in a way that promotes reflection and application in order to give students strength, focus and endurance in the workplace. In addition, we argue that resilience and similar qualities ought to be emphasised in clinical experience courses, internships, work integrated learning and other work experience courses. Recommendations for building resilience in health professionals through education, training and modifications in workplace culture, as well as suggestions for priorities in research are presented.

Introduction

Working in the health professions is a challenge. The work is fast-paced, its nature is changing rapidly, there are many different professional groups with whom one needs to interact, and above all it involves constant helping and human caring – often times with clients and their loved ones who are in crisis. Students typically enter these health professions because they sincerely want to care for others (Skovholt, 2001). Caring for others skilfully involves a high degree of self-giving. Whilst the self can certainly grow and flourish in this altruistic experience, it can also suffer.

Indeed, health professionals do appear to experience a disproportionate share of stress-related issues, including coronary disease, substance abuse and high suicide rates (Wieclaw et al., 2006). Factors that contribute to the stressors in the workplace include: the casualisation of the workforce (Holmes, 2006); staff inexperience and uneven skill mix of untrained and experienced staff (Gillespie et al., 2007); the strain of working with too many patients (Hegney et al., 2006); not having enough time to spend with needy patients (Boykin et al., 2003); the need to make life-changing decisions, sometimes with limited information (Egan, 1993); a great deal of contact with clients and carers who are themselves under duress; and conflict with other busy colleagues with possibly differing agendas (Skovholt, 2001). There is evidence that nurses are the worst affected by this strain (Aiken et al., 2001), although emergency health personnel such as paramedics, ambulance officers and doctors are also potentially vulnerable because of their exposure to extreme stress (Beaton, 2006).

Evidence from nursing studies is relevant to other health professions and shows that collectively nurses have high levels of unhappiness with their limited role, have a low sense of self-efficacy and a high attrition rate (Clinton and Hazelton, 2000, Leighton, 2005). Psychosocially, nurses, who are predominantly women working in a highly bureaucratic and arguably masculinised workplace, experience the negative effects of hierarchy, top-down decision-making, inter- and intra-professional hostility, limited autonomy, public stereotyping and invalidation (Jackson et al., 2007). Also, nurses and the public have tended to devalue rather than showcase special characteristics of their identity, such as being predominantly female, valuing the human connection and using ways of knowing that are personal, subjective and empowering (Lawler, 1991, McAllister, 2007).

In addition, the changing characteristics and expectations of the new generation of health professional graduates add complexity to the situation (Hodges et al., 2005, Holmes, 2006). This younger cohort of individuals tends to perceive hospitals as harsh and unresponsive institutions that offer stressful and unexciting employment opportunities, in which there is widespread unpaid overtime, disparaging and rigid management, limited autonomy, instability, difficult working conditions, and rapid staff turnover (Holmes, 2006).

Another development with huge impact is the changing nature of health services, due largely to the biotechnology boom. Clients are living with, not dying from, chronic diseases and when they access health care they are sicker and have multiple conditions that may complicate both the treatment and the recovery (Gaynor et al., 2006). Thus, the health environment is no longer a stable place where relationships are enduring and is, therefore, potentially much more stressful.

In addition, if students are not prepared for the emotional and cognitive labour involved with caring, then the work can become a burden, leading to stress, burnout and neglect. The cumulative negative consequences of work dissatisfaction and uncertainty, stress and burnout will affect the retention of qualified staff and ultimately hamper recruitment into the very roles that are vital for a healthy society (Fagin, 2001, Hegney et al., 2006). The responses to this problem have been inadequate, as dissatisfaction rises and shortages grow (Aiken et al., 2002). Also, solutions have tended to be restricted to measures that increase supply. There is little knowledge of why clinicians leave the professions, nor why they choose to stay (Gaynor et al., 2006, Leurer et al., 2007). Within this context, research into resilience in health professionals is vital and learning about and applying strategies for resilience should be a relevant, indeed key component of all the curricula for health professions. This paper provides a review of resilience research and theory in order to establish principles for resilience-focused education for students of the health professions.

Section snippets

The nature of resilience

Resilience has been described as an ability to rebound from adversity and overcome difficult circumstances in one’s life (Marsh, 1996) or, alternatively, a process of adaptation to adversity (Newman, 2003). Individuals and groups that display resiliency tend to possess a set of common characteristics that equip them to cope well with life’s vicissitudes.

In the stress-diathesis model of illness, people must first have a biological, psychological, or socio-cultural predisposition to a disorder

The characteristics of resilient individuals

Resilient individuals possess personal attributes such as an internal locus of control, pro-social behaviour, empathy, positive self-image, optimism and the ability to organise daily responsibilities. These attributes enable individuals to build supportive relationships with family members and friends that are used in stressful times (Friborg et al., 2003). In addition, resilient individuals appear to be more adaptable to change than vulnerable people. Through the use of protective resources,

Resilience within contexts and communities

Resilience may also be contextual and dynamic: individuals may not display resilience in all aspects of their lives, and different life transitions that require specific coping mechanisms, social supports or spiritual strength may activate different genetically determined biological reactions (Tusaie and Dyer, 2004). In addition, some resilience resources may be readily available in some contexts but not in others. For example, social supports may be forthcoming in situations that involve

Resilience can be learned

There is convincing evidence that individuals can learn or acquire resilient qualities. Within the positive psychology movement, Seligman’s (1998) work on learned optimism, for example, argued that a person’s explanatory style shapes the meaning and the effect of adverse experiences. Moreover, one can learn to be optimistic by using focused cognitive behavioural techniques that dispute pessimistic thinking and allow the individual to become more adaptive and resilient. Resilient Vietnam

Resilience research in health professionals

As resilience is a personal and cultural strategy for surviving and even transcending adversity, the concept can be used to explore and understand health professionals who survive and thrive in their workplace. Research within health professional groups that experience high exposure to potentially traumatic experiences, such as emergency nurses and ambulance and paramedic personnel, has found that characteristics such as extroversion, openness, agreeableness, conscientiousness and coping levels

Recommendations for building resilience in health professionals via education and workplace learning

Recommendation 1: include discussion of resiliency within all health professional undergraduate education programs. Resilience research has illuminated much that directly relates to the wellbeing of health professionals in the workforce, yet resilience is a concept that has been relatively overlooked in the higher education of health professionals. Predictors of resilience such as cognitive ability, adaptability, positive identity, social support, coping skills, spiritual connection, ability to

Priorities for future research

Research into resilience has elucidated important concepts that are readily applicable to health professionals. Much of the research to date has focussed on clarifying factors that put people at risk or that protect them. Protective factors such as coping mechanisms, social support and spirituality, which are known to help children, youth, older people and those surviving traumatic experiences, are readily applicable to and eminently attainable by health professionals. Thus, research to

Conclusion

There is much within the context of the health disciplines that needs to be explored, understood and disseminated about resilience and growth through adversity. Resilience research offers the health professions exciting opportunities for student education, worker development and workplace enrichment. Emphasis on resilience and related qualities in higher educational programs could assist individuals and professional groups to thrive in busy, dynamic workplaces and attain healthy professional

Acknowledgements

The authors acknowledge Dr Leigh Findlay for editorial assistance with the manuscript. The University of the Sunshine Coast is acknowledged for its support of this work.

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