UNDERSTANDING
PROFESSIONAL RESILIENCE
Mrs Kathryn Gutteridge
Consultant Midwife, Clinical Lead for Low Risk Care, Clinical Psychotherapist
March 2014
UNDERMINING BEHAVIOURS - CHAMPION
Medical
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Belittling someone in public, humiliating
them or accusing them of lack of effort
Spreading gossip or rumours about
someone, teasing or name calling
Ignoring someone's presence,
withholding information or preventing
access to opportunities such as leave or
training
Applying undue pressure on someone to
produce work, setting impossible
deadlines or creating unnecessary
disruptions
Failing to give credit when due, allocating
meaningless tasks, removing someone's
responsibility, moving the goalposts or
repeatedly reminding someone of an
error
RCOG http://www.rcog.org.uk/education-andexams/postgraduate-training/advice-and-supporttrainees/assertiveness-work
Midwifery
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The RCM’s surveys have found that 43%
of students and fully qualified midwives
reported that they had experienced
bullying and harassment from a
colleague.
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Bullying has been cited as a major reason
why many midwives leave the
profession.
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In addition, the 2012 NHS England Staff
Survey reveals that midwives experience
harassment or abuse from managers.
Professor Mavis Kirkham – “Why Midwives Leave”
Penny Curtis, Lynda Ball, Mavis Kirkham
British Journal of Midwifery, Vol. 14, Iss. 1, 05 Jan 2006, pp 27
- 31
WHY DO SOME CLINICIANS MANAGE AND NOT OTHERS?
Example
Research
Most clinicians come into a ‘caring profession’
to meet an unmet need within them.
There has been a fair amount of research
into this area within nursing and more
so latterly within midwifery
From a psychodynamic viewpoint it might be
said that these individuals have some
unconscious unmet element of their
personality.
Midwives particularly work in a high
stress and emotionally charged
dynamic with the balance of care in
two parameters: woman and
fetus/baby.
As a child they may have experienced some
bullying or element of psychological distress
that has fractured trust or self belief. How
this child overcomes this experience will set
the pattern of how they deal with adversity
as an adult.
The Resilient Nurse: Empowering Your Practice
Margaret McAllister, RN, MHN, BA, MEd, EdD; John
B. Lowe, BSc, MPH, DrPH
SURVIVING AND THRIVING?
Clinical Environments
Negative Features of Large
Bureaucracies
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Rapid turnover
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Uneven staff skill mix
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High pressure
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Rapid staff turnover and instability
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Multiple conditions and pathology
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Work conditions are employer focused
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2 lives not one
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Medico-legal perspective
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Media interest in health
Economics is the bottom line
(consequences include widespread
unpaid overtime)
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Disparaging and rigid management
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Controlling (leading to limited worker
autonomy)
‘Health service that clinicians today join
is unlikely to be the comfortable,
predictable, friendly place that is
depicted in television shows like The
Royal or Casualty’.
Source: Adapted from Holmes (2006).
THE STRESS DIATHESIS MODEL
Predispositions
Biological,
behavioural and/or
emotional changes
Stress eg
Life Event
Accumulation of
stress or trauma
Vulnberability
Distress, illness burnout
The model also proposes that people must first have a biological, psychological, or
socio-cultural predisposition to such disorders and must then be subjected to an
immediate stressor to develop disease or abnormality
(Fontaine & Fletcher, 2003).
RISK AND PROTECTIVE FACTORS IN CHILDREN
Risk Factors
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Poor physical health
Low self-esteem
Insecure or unsafe accommodation
Exposure to physical emotional violence
Harmful alcohol, tobacco, drug use
Feeling disconnected with family, school and
community
Lack of meaningful daily activities
Poor problem solving skills
Lack of control over one’s life
Financial hardship
Exposure to environmental stressors (eg school
bullying)
Poor social skills
Parental mental illness
Learning difficulties
Family divorce or separation
Poor coping skills
Protective Factors
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Physical wellbeing, nutrition, exercise and sleep
Self esteem
Secure appropriate and safe accommodation
No harmful alcohol, tobacco and drugs
Positive school climate and community
achievement; supportive caring parent(s)
Meaningful daily activities
Problem-solving skills
Sense of control and efficacy
Financial security
Lack of exposure to environmental stressors
Pro-social peers
Positive optimism
Involvement with significant other person
Availability of opportunities at critical turning
points or major life transitions
Good coping skills
Table Adapted from Bogenschneider (1996).
RESILIENCE
Defining Resilience
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The concept of resilience refers to a
person’s resistance to stress.
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Resilience has been defined in various
ways such as an ability to rebound
from adversity and overcome difficult
circumstances in one’s life (Marsh,
1996);
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a process of adaptation to adversity
(Newman, 2003); and a complex
concept that combines individual,
family, or organisational
characteristics.
Another View Is……
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Resilience is a process of
adapting to adversity that
can be developed and
learned.
RESILIENT ADULTS
Aaron Antonovsky (1987)
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Salutagenesis ….
 Salus –
 Genesis -
Sense of Coherence
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health
origin
Antonovsky studied the influence of various
stressors on health and was able to show
that relatively unstressed people had much
more resistance to illness than those who
were more stressed.
Antonovsky argued that the experience of
wellbeing constitutes a sense of coherence.
That is, “a pervasive, enduring though
dynamic feeling of confidence that one’s
internal and external environments are
predictable and that there is a high
probability that things will work out as well
as can reasonably be expected”
(Antonovsky, 1979, p. 123).
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Meaningfulness
Manageability
Comprehensiveness
Using survivor stories and examples
of situations that seem impossible
but that have been overcome…
Examples Viktor Frankl (1963), emerged
from the Holocaust without the deep
emotional injuries found in many
survivors of the Nazi death camps = now
known as ‘posttraumatic growth’.
Smith, D. (2002). Functional salutogenic
mechanisms of the brain. Perspectives in
Biology and Medicine, 45(3), 319–328.
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SURVIVOR EXAMPLES FOR LEARNING
Segal (1986) summarises the significance of this
survivor research thus:
 In a remarkable number of cases, those who
have suffered and prevail find that after their
ordeal they begin to operate at a higher level
than ever before. . . . The terrible experiences of
our lives, despite the pain they bring, may
become our redemption. (p. 130)
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In this posttraumatic growth research, much has
been learned about the personality and
dispositional characteristics of resilient people.
Research has explored cancer survivors
(Rowland & Baker, 2005), people living with AIDS
(Rabkin, Remien, Williams, & Katoff, 1993),
people who are ageing (Ryff, Singer, Love, &
Essex, 1998), and people who endured the
tragedy of the September 11 attacks (Butler et
al., 2005).
DEVELOPING INTERNAL RESOURCES
Personal Attributes
Internal locus of control
Good social support
systems where pastoral
as well as health care is
acknowledged
Good coping and
problem solving skills
Pro-social behaviour
Empathy, positive self image,
optimistic view & ability to
organise
Daily responsibilities enable
individuals to build supportive
relationships with team,
clients, patients and home
KEY ATTRIBUTES CONSISTENT WITH RESILIENT
INDIVIDUALS
5 Components
Social
environments
Physical
environments
Family
Connectedness
Spiritual life
that is lived out
Sense of inner
wisdom
FINDING A WAY FORWARD
Resilience & Health Professionals
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Building positive professional relationships
through networks and mentoring
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Maintaining positivity through laughter,
optimism, and positive emotions
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Developing the emotional insight to
understand one’s own risk and protective
factors
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Achieving life balance and using spirituality
to give one’s life meaning and coherence
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Becoming more reflective, which helps
access emotional strength and assists in
meaning making and thus, in transcending
the present ordeal.
Practical Elements
Jackson et al. (2007) argue for the need to
teach and encourage all health
professionals to:
 Identify their own risk and protective
factors
 Share experiences of both
vulnerability and resilience so that
others may learn from—and perhaps
emulate—the strengths and also avoid
the pitfalls
 Acknowledge and praise success in
peers’ achievements
 Promote feelings of pride
 Encourage STORYTELLING and Role
Play
Jackson, D., Firtko, A., & Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in
the face of workplace adversity: A literature review. Journal of Advanced Nursing, 60(1), 1–9.
LEARNED OPTIMISM AND RESILIENCE
Work of Seligman (1998)
Developing – ‘Pay it Forward’
One can learn to be optimistic by using
focused cognitive behavioural
techniques that dispute pessimistic
thinking and thus, become more
adaptive and resilient.
For example, optimists don’t give up as
easily and don’t see an adverse
situation as permanent; optimists
think that bad things happen
sometimes, not all the time;
optimists don’t always blame
themselves when bad things
happen—rather they see that the
situation or external factors may
have been the cause.
Resilient healthcare professionals have the
ability to expect stress and adversity,
they expect it to happen.
There is also an expectation that work areas
can be protective against increasing
stressors; so calming environments that
are prepared for highly charged events
helps.
 Frankl showed us that resilience was
more than withstanding stress and
distaster it was about giving something
back – generativity - setting a good
example, mentoring, leading, coaching,
and motivating others, is a practice that
could be learned by and strengthened in
those entering the health professions.
Seligman, M. (1998). Learned optimism. New York, NY:
Random House.
CHART ADAPTED FROM CHARNEY (2004).
Character
Description of how to cultivate characteristics
Optimism
Strongly related to resilience, Optimists usually have decreased autonomic
arousal, use more adaptive coping strategies, and seek supportive relationships during
crises . Can be learned through Cognitive Behaviour Therapy
Cognitive flexibility
Ability to restructure knowledge in adaptive
ways in response to changing demands. Reduces incidence of posttraumatic stress disorder
after combat. Speeds recovery after loss of a family member or natural disaster
Personal moral compass
Helps people get through adversity. Many victims of Hurricane Katrina and 9/11 attributed
their survival to faith, either through religion or through spirituality
Altruism
Coping with extreme stress is often made easier by helping others
Having a role model who
demonstrates resilience
Find a mentor or heroic figure . Imitation is a powerful mode of learning; resilience heroic
figures inspire us to greatness, even though they might not achieve success
Adeptness at facing fears
Recognise that fear is normal and can be fears used as a guide. Practise skills needed to get
through fears
Active coping skills
Create positive statements about the self in relation to a threat. Seek active support from
others
Supportive social network
Value seen dramatically after 9/11 and network Hurricane Katrina; intense debriefing
doesn’t seem to help Emotional strength comes from close, meaningful relationships
Physical fitness
Exercise is good for physical wellbeing, and also enhances brain health and plasticity
Sense of humour
Narrows gap between doctors and midwives. Narrows gap between carers and patients,
especially children, who often feel helpless and forlorn. Helps women/patients cope with
their illness
REFERENCES
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Bogenschneider, K. (1996). An ecological risk/protective theory for building prevention programs, policies, and community
capacity to support youth. Family Relations, 45(2), 127–138.
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Butler, L., Blasey, C., Garlan, R., McCaslin, S., Azarow, J., Chen, X., . . . Spiegel, D. (2005). Posttraumatic growth following
the terrorist attacks of September 11, 2001: Cognitive, coping, and trauma symptom predictors in an internet
convenience sample. Traumatology, 11(4), 247–267.
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Charney, D. S. (2004). Psychobiological mechanisms of resilience and vulnerability: Implications for successful adaptation
to extreme stress. American Journal of Psychiatry, 161(2), 195–216.
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Curtis. P, Ball. L, Kirkham . M. (2006) British Journal of Midwifery, Vol. 14, Iss. 1, 05 Jan 2006, pp 27 - 31
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Fontaine, K., & Fletcher, S. (2003). Mental health nursing (5th ed.). Upper Saddle River, NJ: Pearson.
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Holmes, C. (2006). The slow death of psychiatric nursing: What next? Journal of Psychiatric and Mental Health Nursing,
13(4), 401–415.
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Jackson, D., Firtko, A., & Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of
workplace adversity: A literature review. Journal of Advanced Nursing, 60(1), 1–9.
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McAllister. M; Lowe, J.B (2011). The Resilient Nurse: Empowering Your Practice, Springer Publishing: New York.
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Marsh, D. T. (1996). Marilyn . . . and other offspring. Journal of the California Alliance for the Mentally Ill, 7(3), 4–6.
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Newman, R. (2003). Providing direction on the road to resilience. Behavioral Health Management, 23(4), 42–43.
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Rabkin, J., Remien, R., Williams, J., & Katoff, L. (1993). Resilience in adversity among long-term survivors of AIDS. Hospital
and Community Psychiatry, 44(2), 162–167.
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Rowland, J., & Baker, F. (2005). Resilience of cancer survivors across the lifespan. Cancer, 101(11 Suppl.), 2543–2548.
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Ryff, R., Singer, B., Love, G., & Essex, M. (1998). Resilience in adult and later life. In J. Lomranz (Ed.), Handbook of aging
and mental health: An integrative approach (pp. 69–96). New York, NY: Plenum Press.
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Segal, J. (1986). Winning life’s toughest battles (p. 130). New York, NY: McGraw-Hill.
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Seligman, M. (1998). Learned optimism. New York, NY: Random House.