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Received: 6 February 2018 Revised: 10 April 2018 Accepted: 3 May 2018 DOI: 10.1111/jpm.12467
ORIGINAL ARTICLE
Strengthening mental health nurses’ resilience through a workplace resilience programme: A qualitative inquiry Kim Foster RN, PhD, Professor of Mental Health Nursing1,2
| Celeste Cuzzillo GradDipPsych,
Research Support Officer1,2 | Trentham Furness PhD, Postdoctoral Research Fellow1,2 1 School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Vic., Australia 2
NorthWestern Mental Health, Melbourne Health, Parkville, Vic., Australia Correspondence Kim Foster, Mental Health Nursing Research Unit, Australian Catholic University and NorthWestern Mental Health, The Royal Melbourne Hospital, Grattan Street, Parkville, Vic. 3050, Australia. Email:
[email protected] Funding information Office of the Chief Mental Health Nurse; Department of Health and Human Services; Victorian Government
Accessible summary What is known on the subject? • Mental health nurses are affected by interpersonal, practice-related and organizational factors that can increase workplace stress and reduce their physical and mental health and well-being. • Resilience programmes are a strength-based preventative approach to supporting individuals to overcome workplace adversities. What the paper adds to existing knowledge? • This qualitative inquiry is the first study to report mental health nurses’ perspectives and experiences on a workplace resilience programme. • Strengthening mental health nurses’ resilience through a resilience programme involved a process of understanding resilience, and applying resilience strategies such as positive self-talk, managing negative self-talk, detaching from stressful situations, being aware of and managing emotions, and showing more empathy, to address workplace challenges. • To address the range of resources needed to support mental health nurses’ resilience, a social–ecological approach to workplace resilience can be used to promote resource provision at individual, work unit, organizational and professional levels. What are the implications for practice? • Resilience programmes are one resource for addressing the impacts of workplace stressors on mental health nurses. Organizational barriers and risks to staff wellbeing need to also be addressed to build a resilient workforce. • Incorporating resilience strategies into clinical supervision or reflective practice models may help sustain beneficial outcomes following a resilience programme and support resilient practice.
Abstract Introduction: Mental health settings are potentially high-stress workplaces that can lead to nurses’ poorer health and well-being. Resilience programmes are a strengths- based preventative approach for promoting mental health and well-being in the face of adversity; however, there is no prior research on mental health nurses’ perspectives on resilience programmes. Aim: To explore the perspectives of mental health nurses participating in a mental health service-initiated resilience programme (Promoting Adult Resilience). J Psychiatr Ment Health Nurs. 2018;1–11.
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Method: An exploratory qualitative inquiry was undertaken. Multiple qualitative data: open-ended responses and semi-structured interviews and focus groups, were thematically analysed. Results: Twenty-nine registered nurses from a metropolitan mental health service participated. Four main themes were as follows: being confronted by adversity; reinforcing understandings of resilience; strengthening resilience; and applying resilience skills at work. Discussion: This is the first study to report mental health nurses’ perspectives on a resilience programme. Resilience programmes can help improve nurses’ self-efficacy and ability to realistically appraise stressful situations and to moderate their emotional responses to others. Implications for practice: It is recommended resilience programmes are provided to promote nurses’ well-being and resilient practices. To build a resilient workforce, the wider barriers and risks to staff well-being need to be addressed at a unit, organizational and professional level. KEYWORDS
mental health promotion, professional development, qualitative methodology, stress management
1 | I NTRO D U C TI O N
dissatisfaction (Baum & Kagan, 2015) and work–life conflict (Luther
Mental health settings are potentially high-stress workplaces for
mental health outcomes for staff including cardiovascular diseases
nurses due to a range of interpersonal, practice-related and organi-
(Kelley, Fenwick, Brekke, & Novaco, 2016), depression (Wang et al.,
zational factors (Dobie, Tucker, Ferrari, & Rogers, 2016; Tonso et al.,
2015) and post-traumatic stress disorder (Hilton, Ham, & Dretzkat,
2016). From an interpersonal perspective, stressors include the
2017; Jacobowitz, 2013). Of significance, the cumulative negative
et al., 2017). Unresolved stress can result in poorer physical and
emotional labour of managing challenging situations such as suicidal-
effects of workplace stress on MHN well-being can compromise the
ity, and building effective relationships with mental health consum-
quality of care provision (Rössler, 2012) and therapeutic practice
ers and families (Delgado, Upton, Ranse, Furness, & Foster, 2017;
(Roche, Duffield, & White, 2011) and affect nurses’ retention in the
Edward, Hercelinskyj, & Giandinoto, 2017). Other interpersonal
workforce (Hungerford & Hodgson, 2013).
stressors include being confronted with consumer-related violence
There is an evident need to reduce workplace stressors and ad-
and aggression (Itzhaki et al., 2015; Zarea, Fereidooni-Moghadam,
dress the harmful impacts of workplace stress on nurses. Resilience
Baraz, & Tahery, 2017), colleague-related conflict (Ennis, Happell,
is a strengths-based preventative approach to support individuals to
Broadbent, & Reid-Searl, 2013) and/or bullying (Cleary, Hunt, &
overcome and thrive in the context of adversities and major stress-
Horsfall, 2010). In respect to their practice, mental health nurses
ors (King & Rothstein, 2010). In the wider field of nursing, personal
(MHN hereafter) report that lack of role clarity (i.e., what is expected
resilience is described as an individual’s traits, characteristics or
from them) (Hanna & Mona, 2014), insufficient numbers of staff with
qualities (Jackson, Firtko, & Edenborough, 2007) that help equip
high-quality practice skills and values (Jones & Gregory, 2017), and
them to cope well with adverse events and situations (McAllister
changing consumer risk profiles and associated containment and ob-
& McKinnon, 2009). Resilience in the context of the workplace has
servational practices (Barnicot et al., 2017) can be challenging and
also been referred to as professional resilience (Cleary, Jackson, &
stressful. From an organizational perspective, stressors include high
Hungerford, 2014). Resilience may improve the quality of clinicians’
acuity and high workloads (Yanchus, Periard, & Osatuke, 2017) in the
care provision (Jackson et al., 2007) and reduce the stress (Foureur,
context of inadequate staffing resources (McTiernan & McDonald,
Besley, Burton, Yu, & Crisp, 2013) and burnout (Craigie et al., 2016)
2015), lack of effective clinical leadership (Ennis et al., 2013) and in-
associated with workplace stressors.
adequate clinical supervision (White & Winstanley, 2010).
There is limited literature, however, on resilience in the special-
These workplace stressors can significantly affect MHN well-
ist field of mental health nursing. Most of this has emerged only
being and practice and negatively impact workforce retention.
recently. In a qualitative study using a social–ecological approach,
Workplace stress and high emotional demands are known to increase
MHN reported resilience as a personal capacity enabling them to
MHN emotional dissonance and burnout (Edward et al., 2017), job
thrive in practice when they understood themselves and their life’s
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purpose, and engaged in meaningful reflection on their practice (Marie, Hannigan, & Jones, 2017). Other qualitative study findings
2 | PRO M OTI N G A D U LT R E S I LI E N C E (PA R ) PRO G R A M M E
describe how MHN resilience can be supported through peer group feedback, professional development, dissemination of clinical good
The PAR programme is an evidence-based multimodal resilience-
practices (Edward, 2005) and having strong rapport with consumers
building programme that aims to promote adult resilience, improve
(Warelow & Edward, 2007). Quantitative study findings include that
mental health and well-being, strengthen relationships and reduce
MHN resilience is positively correlated with job satisfaction (Matos,
conflict through increasing communication at work and encouraging
Neushotz, Griffin, & Fitzpatrick, 2010), life satisfaction (Itzhaki et al.,
the use of stress management strategies (Millear, Liossis, Shochet,
2015; Zheng et al., 2017) and self-esteem (Gito, Ihara, & Ogata,
Biggs, & Donald, 2008; Shochet, Wurfl, Hoge, Liossis, & Millear,
2013).
2008). The programme has been trialled with resource sector em-
It is important to acknowledge that promoting personal resil-
ployees and public servants, demonstrating improved mental health
ience at work is the responsibility of organizations and employers
and coping and self-efficacy outcomes (Liossis, Shochet, Millear,
as well as individuals and that resilience can be understood within
& Biggs, 2009; Millear et al., 2008). The programme has also been
a social–ecological framework. From an ecological perspective,
adapted for the high-stress profession of the police force, with posi-
being able to overcome adversity is less dependent on individual
tive ratings on programme usefulness and the cognitive restructur-
factors and more on the interactional processes between a per-
ing components (Shochet et al., 2011).
son’s social and physical ecology (Ungar, 2011). This emphasizes
The PAR programme has a strengths-based and salutogenic focus
people’s capacity to find resources that sustain their well-b eing
and is delivered face-to-face in a peer group setting by accredited
and the capacity of their environment, including workplace, family
facilitators using a range of teaching modalities including manualized
and community, to provide them (Ungar, 2008). Psychological re-
workbooks, PowerPoint, group discussion (both large and small) and
silience is therefore a dynamic and interactional process of recov-
individual activities (Shochet et al., 2008). The programme theory has
ery from adversity where adaptive responses lead to restoration
been drawn from cognitive–behavioural and interpersonal therapy
of well-b eing through multiple internal (individual) and external
traditions, which have been integrated together in the programme
(environmental) protective factors and self-regulatory processes
model and activities (Shochet et al., 2008). A major focus is empha-
(King & Rothstein, 2010; Masten & Obradovic, 2006). There are
sizing and building participants’ interpersonal strengths, developing
many pathways to resilience (Masten & Obradovic, 2006). This
skills for managing stress and mental well-being, and building re-
highlights the potential to strengthen the interaction between
sourcefulness (Shochet et al., 2008). In the standard programme, PAR
MHN and their environment to modify risk and protective pro-
is delivered over 7 weeks with one module/week. The modules focus
cesses and to provide resources that can support nurses’ positive
on: recognizing strengths and understanding resilience, understand-
adaptation in the face of workplace adversities. There is a criti-
ing and handling stress, challenging and changing negative self-talk,
cal imperative for organizations to help sustain MHN well-b eing
drawing strength from hardship, supporting positive relationships,
in healthcare environments characterized by ongoing adversity
managing conflict, generating solutions for well-being and bringing it
to support them in their therapeutic work and to help retain the
all together (Shochet et al., 2008). With permission of the programme
workforce.
developers, the education delivery was adapted for the current set-
Although there is literature describing MHN resilience and cor-
ting by integrating the seven modules into two full-day workshops,
relates of mental health (e.g., Itzhaki et al., 2015; Matos et al., 2010;
which were offered 3 weeks apart. This made it feasible for managers
Zheng et al., 2017), and emerging reports of resilience programmes
to release staff from their shifts to attend. Further, to tailor the pro-
for the wider nursing profession (e.g., Craigie et al., 2016; Guo et al.,
gramme for the workplace context of mental health nursing, a post-
2017; McDonald, Jackson, Wilkes, & Vickers, 2012), there are no
traumatic growth module (drawing strength from adversity) from
prior reports on resilience programmes for MHN. There is a recog-
another PAR-adapted programme was included (Shochet et al., 2011).
nized need to implement resilience programmes for the profession (Cleary et al., 2014; Edward et al., 2017) and to investigate how such programmes may develop MHN resilience. Understanding the im-
2.1 | Programme delivery
pacts of resilience programme implementation on nurses’ resilience
The programme was codelivered by accredited PAR facilitators at a
may assist in improving the well-being of the MHN workforce. The
designated learning centre within the organization over two full-day
overall aim of this qualitative inquiry was to explore the experiences
workshops delivered 3 weeks apart. The workshops were usually
and perspectives of mental health nurses participating in mental
cofacilitated. Facilitators were experienced senior nurses who were
health service-initiated resilience programme (the Promoting Adult
trained and accredited by the programme developers in the pro-
Resilience (PAR) programme). Research questions were as follows:
gramme delivery prior to its implementation. Facilitators received
What were mental health nurses’ perspectives on the resilience pro-
ongoing supervision in programme delivery by the programme devel-
gramme?; What were their understandings of resilience in the con-
opers throughout programme implementation. To reinforce learning
text of their work and life?; and How did nurses apply their learnings
activities, between workshops participants were sent two booster
on resilience to their work?
emails and one email per month for 3 months after the final workshop.
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FOSTER et al.
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TA B L E 1 Participant characteristics N = 29 Age
Gender
3 (10)
30–39
6 (21)
40–49
9 (31)
consent. There were two participant groups: the participants who
≥50
10 (35)
completed the PAR programme and the facilitators who delivered
Missing
1 (3)
the programme. The study was conducted in a large metropolitan
Male
8 (28)
public mental health organization in Australia in the context of the
21 (72)
implementation of a new resilience education programme for MHN.
RN level
1
2 (7)
2
14 (48)
3
6 (21)
4
2 (7)
verbal study information and provided written informed voluntary
3.3 | Data collection Multiple qualitative data were collected: prior to the first PAR work-
5 (17)
shop day (T1), after the second workshop (T2) and 3 months follow-
16 (55)
ing the second workshop (T3). There were three main data sources:
Senior clinicians
13 (45)
open-ended written data on participants’ (n = 24) understandings of
≤5
8 (28)
resilience and what they had learnt about resilience (T1, T2 and T3);
6–9
9 (31)
10–14
7 (24)
15–19
4 (14)
Years in current role
≥20 Years in a mental health setting
Specialist mental health qualification
health was recruited. All participants were provided with written and
RPN
5
Full-time equivalent
A purposive sample of n = 29 registered nurses working in mental
18–29
Female
Current role
3.2 | Participants and setting n (%)
1 (3)
and individual semi-structured interviews with participants (n = 4), a focus group (n = 3) with participants; and a focus group with facilitators (n = 5), at T3. Interviews were conducted via telephone at a mutually convenient time. Focus groups were held in quiet rooms in the health service at a mutually convenient time. Interview and focus
≤5
3 (10)
6–9
3 (10)
10–14
6 (21)
For instance, facilitators were asked “What effect/s, if any, do you
15–19
9 (31)
think the program has had on staff confidence and capacity to use
≥20
8 (28)
their strengths and resources in the context of workplace stress?”
Full-time
22 (76)
Participants were asked what they had learnt about resilience, and
Part-time
6 (21)
how they had applied this to their work and life. For example, “What
Missing
1 (3)
have you learnt about resilience from the program?” and “How, if at
Yes
23 (79)
No
3 (10.5)
Missing
3 (10.5)
Notes. RPN, Registered Psychiatric Nurse.
group questions sought participant and facilitator perspectives on the programme and its usefulness, with prompts for examples.
all, have you applied what you’ve learnt to your work?” (with prompts for examples of how participants now responded to challenges). Data were collected between November 2016 and April 2017. Interviews and focus groups ranged between 17 and 52 min, with an average of 32 min. Interview and focus group data were audio- recorded, then transcribed verbatim, integrated with field notes, and deidentified. Open-ended written data were entered into an Excel spreadsheet. All data were managed using QSR International’s
3 | M E TH O DS 3.1 | Research design
NVivo 11 software for analysis.
3.4 | Data analysis
The study was conducted as an exploratory qualitative inquiry as
Multiple qualitative data were triangulated: open-ended written
part of a larger mixed methods study investigating the feasibility
responses, semi-structured participant interviews, and participant
of the PAR workplace resilience programme with MHN (Foster et
and facilitator focus groups. Data were thematically analysed using
al., 2018). An exploratory design is appropriate when little is known
an inductive approach. This allows for analysis of varied forms of
about a topic and where in-depth understanding of a phenomenon
data to be condensed and synthesized (Thomas, 2006). The pro-
is needed (Merriam, 2009). In this study, there was a lack of un-
cess involved immersion in the data and reading for key concepts,
derstanding of MHN perspectives on workplace resilience educa-
initial coding, then clustering of codes into categories which were
tion. This study was approved by the Melbourne Health Office for
collapsed and sorted into themes (Green et al., 2007). Emergent
Research (LNR/16/MH/355 and LNR/QA 2016160).
themes were discussed and refined by the first two authors, who
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FOSTER et al.
were trained and experienced qualitative researchers, in an iterative
Achieved my heart’s desire to become a nurse with all its
process until agreement was reached on final themes.
ups and downs in between. At the moment I am where I want to be. I’m happy with my work and I love working….
4 | FI N D I N G S A total of 29 nurses participated (see Table 1). Nurses were evenly spread across age ranges, and most (72%) were female. Most (76%) nurses were employed full-time and 12 (41%) had been in their cur-
(Interview 3)
4.2 | Reinforcing understandings of resilience Nurses identified that rather than providing new understandings,
rent role for at least 10 years. Four main themes were identified from
the PAR programme mainly reinforced their understandings of re-
analysis: being confronted by adversity; reinforcing understandings
silience and helped them understand more clearly what resilience
of resilience; strengthening resilience; and applying resilience skills
was; “It clarified in my mind more than anything else” (Interview 1).
at work.
They attributed this to having prior knowledge of resilience through university studies or professional development. However, their understandings of resilience did adapt over time to reflect the pro-
4.1 | Being confronted by adversity
gramme theory and their conceptualizations of resilience became
In reflecting on the programme and its usefulness, nurses identified
more succinct and holistic (see Table 2 open-ended responses for
a range of workplace stressors including physical aggression from
examples). At the beginning, nurses tended to refer to resilience in
consumers, staff conflict or aggression, and consumer suicides or
relation to either their work or life. By 3 months following the pro-
self-harm. Some also described personal stressors including relation-
gramme, they viewed resilience more generally (Table 2) including a
ship conflicts and experience of violence. Workplace violence was a
progressive understanding of how resilience was not only an ability
prominent stressor, and one nurse explained how this had affected
to cope but also the capacity to learn and grow and to recover and
their psychological well-being:
thrive. Nurses most often described resilience as being able to cope
I was assaulted at work…I was punched in the head mul-
with a “stressful situation,” “managing my emotions” and “moving on”
tiple times and it was more psychological trauma that I
after they had faced stressors. Some considered personal growth
had to take time off for…not permanent [physical] inju-
to be part of resilience and that it was important to harness their
ries. I’ve kind of had some PTSD and stuff from the as-
strengths to solve problems and address challenges. One nurse ex-
sault.
plained resilience as:
(Interview 4)
Many nurses found the most challenging stressors were “expe-
…you grow and you learn and excel through hardship.
riences that are very emotionally charged,” particularly consumer-
That doesn’t mean that you can’t be affected by some-
related verbal abuse or aggression. Some found staff conflict and
thing but that in time you use that positively, or to im-
aggression more of a concern because it was difficult to manage or stay
prove yourself, or improve your practice in some way as
out of the conflict. Nurses identified situations which they perceived
you go on.
(Interview 2)
as out of their control or where they felt they could have changed the outcome as particularly stressful. A few found suicide to be the most challenging:
Others understood resilience as being an individual experience involving how each person perceived and overcame adversity –”everyone does it differently.”
…aggression you deal with and you move on, whereas a suicide gives you the ‘what ifs’ and ‘how about if I did this’ or ‘could the outcome have been different? (Focus Group 1)
4.3 | Strengthening resilience Nurses found that the programme strengthened their resilience through identifying resilience skills they and others were already
Some nurses observed that work stressors were different to those
using successfully, reminding them of particular areas they could im-
at home and that they were more able to be resilient at work due to the
prove and providing an opportunity to learn from the programme
less personal nature of the relationships. One nurse attributed their
and each other. Nurses most commonly spoke of how the education
resilience to having overcome personal adversity earlier in life:
reaffirmed, strengthened and gave name to their current practices:
I witnessed domestic violence…went through civil war…
We have strengths but we often don’t know we have
disruption of my education. I had childhood difficulties,
[them] and if they’re pointed out to us or new strengths
poverty during the civil war, and immigrated to Australia.
taught or we are taught new ways to handle difficult sit-
Very little money and even less English. Worked hard.
uations that helps with stress.
(Interview 3)
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FOSTER et al.
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TA B L E 2 Resilience understandings over time
colleague of mine as ‘seething behind a computer’ so that
Participant A
was really difficult to hear when I know [nurse] had just
T1: “Ability to be able to manage and cope through difficult and stressful situations even when the stress is cumulative. It’s the ability to get out of bed and smile each morning no matter what”
with how to help these other people, so it’s just kind of a
T2: “The ability to grow and learn and develop in the face of difficult or traumatic situations”
been assaulted that morning…maybe they’re not coping really stressed system in my opinion….
(Interview 1)
Nurses found that the programme’s peer group setting enabled
T3: “The capacity to recover quickly from difficulties”
them to learn from each other, which facilitated rapport and strength-
Participant B
ened their relationships. Hearing about others’ challenging experi-
T1: “Going strong by experiencing hardship, difficulty, having flexibility of thinking, applying different thinking styles so that I could come up with solutions to my problems, adapting to different situations just like a bamboo, resilience is adapting to different directions of the wind but remaining rooted on the ground”
ences helped them feel connected and to realise they weren’t alone.
T2: “Resilience to me is being able to adapt, apply flexibility in dealing with difficult situations then to bounce back, ensuring that I maintain mental, emotional, intellectual and physical stability”
They drew strength from each other’s experiences and also drew on their colleagues for support: Slowly it is changing and we tend to support each other. I find when the stress and the workload are unacceptably high we tend to support each other more. (Interview 3)
T3: “Recovering quickly from any difficulties/problems” Participant C T1: “The way you cope with work pressure, stress and other issues” T2: “Resilience is your ability to adapt yourself to stressful situations and staying calm and understanding other people’s issues” T3: “Abilities to thrive in situations of ongoing pressure”
Several nurses commented on the benefits of the post-traumatic
Some nurses found that the programme strengthened resilience in their personal life. They viewed their experiences at work as different to those at home, but considered that the resilience strategies they learnt were transferable “…[we] see the best and worst of situations at work and I think it… sort of translates into everyday life.”
4.4 | Applying resilience skills at work
growth module. The activities provided them with the space and time
Nurses found the resilience strategies particularly useful for manag-
to think about the positive learnings they could take away from stress-
ing challenges at work and improving their practice. These included
ful events, which in turn could help them to grow. One nurse described
using positive self-t alk, managing negative self-t alk, detaching from
their experience of significant personal growth and strategies they
stressful situations, not taking things personally, being aware of and
learnt in the programme after a violent incident with a consumer:
managing emotions and showing more empathy towards colleagues and consumers. Nurses most often identified that using positive self-
…there was a massive growth post [incident]. It took me
talk strategies and challenging negative thought traps helped them
a little while to get there but I think, yeah, going through
to reframe stressors, find solutions to problems and respond more
it [incident] was probably one of the most difficult ex-
effectively “when confronted with challenging [consumers] and
periences of my life but it’s been probably the most pro-
challenging situations” (open-ended response). Nurses identified
ductive. So I’ve grown as a person, as a clinician. I look at
that cognitive behavioural skills were particularly useful for coping
things a lot differently in my practice when dealing with
with work stressors. Some had “started to look at things differently,
aggressive [consumers] and… I don’t feel like I probably
tried the self-t alk, used my strengths” (open-ended response) to
would be at the point where I am in my life now if that
manage their emotions and responses. Nurses found these enabled
kind of hadn’t happened…I think I have learnt to care for
them to “detach from a stressful situation” and “see a situation as a
myself, I guess. Actually recognise those things that you
blank space” rather than making assumptions:
might not be coping with…and actually ask for help. It was very unpleasant but I definitely have grown and de-
I think that it’s good that it uses…a basic CBT foundation
veloped as a direct result of that incident. (Interview 4)
and I think that out of…my own personal life, that I look at things under that framework at times, or have used
Several nurses identified that the programme reinforced the need to self-care regularly and to look after their well-being and that
that in helping [consumers], so I think that it’s a good foundation.
(Interview 2)
of their colleagues. Others, however, acknowledged that colleagues could sometimes be judgmental and unsupportive when nurses were struggling:
Through the programme, nurses also developed strategies to manage their emotional responses:
I’ve seen staff really kind of talking badly about nurses
I try and keep my emotions out of how I’m dealing with
that look like they’re stressed -they described one nurse
[consumers] and staff. I just try to be aware of what I’m
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FOSTER et al.
actually feeling, I try not to let that emotion overtake my
self-t alk and promoting positive self-t alk to be particularly helpful.
behaviours, and kind of acknowledge ‘I’m feeling anxious
These findings are consistent with previous PAR participants, who
right now’, but still try and use my rational brain to deal
reported that learning positive self-t alk, identifying and building on
with the situation and then reflect back on the emotion
strengths, and being able to share work concerns with colleagues
later and see what might have caused that, or how I might
were especially useful (Millear et al., 2008; Shochet et al., 2011).
manage that emotion in a healthy way…
(Interview 1)
An improved ability to emotionally self-regulate was an important finding. Nurses reported that being able to identify and
The programme had reinforced for many that “there’s some-
acknowledge negative emotions, but not act on them, was key to
thing you can do about [workplace stress]. You don’t have to burn
managing demanding interpersonal situations including verbal and
out. You don’t have to leave, you can actually try these things and
physical aggression. This indicates nurses were using emotional
it might make it different for you” (Focus Group 2). This included
intelligence: identifying and regulating emotions and using them
an improved ability to communicate with colleagues as nurses were
to guide thinking and problem-solving (Mayer, Salovey, & Caruso,
“more confident to address colleagues in conflict resolution” (open-
2004). Emotional intelligence strategies are important protective
ended response). Some also improved their ability to empathize with
processes in personal resilience (Foster & Robinson, 2014) and
consumers and colleagues as the programme reminded them to take
crucial skills for nurses, which can be developed and improved
a step back and “consider the other side of the story before jumping
through education (Foster et al., 2017). Being able to emotionally
to conclusions” (open-ended response). Several nurses suggested
self-regulate is a key ability for effective mental health nursing prac-
that the resilience strategies they had learnt could be reinforced
tice, for preventing burnout and for mitigating the negative aspects
after the programme through “a trusting relationship” in ongoing
of emotional labour (Edward et al., 2017). If nurses are more able
clinical supervision or reflective practice, including in a group con-
to manage their own emotional states, they may experience better
text where they could get peer support, e.g., in “resilience reflective
mental health, practice more therapeutically and role model emo-
practice.”
tional regulation when working with consumers. Conversely, emo-
Nurses also acknowledged, however, that there were structural or organizational stressors such as high acuity, lack of beds, lack of
tional dysregulation is a core feature of mental ill health (Berking & Wupperman, 2012).
staff or high workloads, which could not be addressed by the pro-
Emotional regulation was also part of nurses’ description
gramme. While they could manage their own responses to these
of how they applied what they had learnt on resilience to their
stressors more effectively through resilience strategies, structural
practice. These “resilient practices” (Warelow & Edward, 2007)
barriers meant that they could not necessarily improve the contrib-
involved cognitive, emotional and behavioural responses to stress-
uting factors to the stressful situation:
ful situations that enabled the nurses to respond successfully in challenging interpersonal interactions and to provide more effec-
I can leave my office… and give assistance but I actually
tive care in complex situations. In the current study, resilient prac-
can’t remove the causative factor, which is the pressure,
tices included self-t alk strategies, detaching from emotions, using
the under-resourcing, the staffing, and that for me is re-
emotions to problem-solve, and the use of empathy. Empathic
ally big.
(Focus Group 1)
engagement is recognized as a core feature of effective therapeutic relationships in mental health nursing and is particularly helpful in conflictual situations with consumers, where its use can influ-
5 | D I S CU S S I O N
ence the satisfaction of both nurse and consumer (Gerace, Oster, O’Kane, Hayman, & Muir-Cochrane, 2018). This transactional form of empathy involves differences between clinicians and consumers
This is the first study to report on MHN experiences and perspec-
that need to be negotiated in order for the consumer to engage and
tives on a resilience programme and to explore nurses’ perspectives
participate in their recovery and care (Ross & Watling, 2017). There
on the programme, understandings of resilience in the context of
is neurobiological evidence that emotion regulation and empathy
work and life, and how they applied their learnings on resilience to
are associated, and empathic responses are more likely in interper-
their work. There were several key findings. Nurses were positive
sonal situations when negative emotions have been self-regulated
about the programme and reported that it helped improve their self-
(Schore, 2014). Importantly, the findings from the current study
efficacy and ability to realistically appraise stressful situations and
indicate that MHN can benefit from and learn through resilience
to moderate their emotional responses in order to interact effec-
education to more effectively regulate themselves, be empathic,
tively with consumers and colleagues. Self-efficacy, emotional self-
practice therapeutically in emotionally tense and/or conflictual sit-
regulation and adaptive cognitive appraisal are recognized protective
uations with consumers.
processes in a resilient response to stress (Bailey, Sharma, & Jubin,
The PAR resilience programme included the addition of a post-
2013; Masten & O’Dougherty Wright, 2010). Nurses in the current
traumatic growth (PTG) module from another PAR-adapted pro-
study also valued the collegial peer group interaction and perceived
gramme (Shochet et al., 2011). Post-t raumatic growth involves the
the cognitive–behavioural strategies such as managing negative
experience of positive change and growth that can occur out of
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FOSTER et al.
8
the struggle individuals can go through following crises and trau-
6 | I M PLI C ATI O N S FO R PR AC TI C E
matic events. This includes a renewed appreciation of life, changed priorities, improved personal relationships and a greater sense of
Rather than asking nurses to do more or better, to build a resil-
personal strength (Tedeschi & Calhoun, 2004). Participants in the
ient workforce the wider organizational barriers and risks to staff
current study reported personal growth, which was facilitated by
well-being need to be addressed in addition to individual strategies
the PAR programme, following critical incidents such as violence.
such as resilience programmes. An ecological view of resilience in-
In an important way, the programme reinforced that both posi-
cludes the understanding that overcoming adversity involves an in-
tive (e.g., PTG) and negative (e.g., post-t raumatic stress) outcomes
teractive process of using individual and environmental resources
could coexist following traumatic events (Shakespeare-F inch et al.,
(Ungar, 2011). Based on the findings of this study, and taking a so-
2014). Mental health nursing is recognized as a high-s tress pro-
cial–ecological approach to resilience, Figure 1 and Table 3 outline
fession with substantial workplace violence, and MHN life satis-
resources that can be promoted at individual, work unit, organiza-
faction has been found to be more affected by PTG and resilience
tional and professional levels to strengthen nurses’ well-being and
than by violence (Itzhaki et al., 2015). We recommend that future
resilient practices. At an individual level, it is recommended that this
resilience programmes include PTG modules to support MHN in positive meaning-making and well-b eing following critical workplace incidents. To sustain and build resilience strategies after programme completion, participants recommended that resilience strategies be incorporated in clinical supervision or reflective practice models. Professional resilience can be strengthened, and stress and burnout reduced, through restorative group clinical supervision, a model designed to support clinicians whose practice involves high emotional demands (Wallbank, 2013). This clinical supervision approach may be particularly relevant for MHN as their work includes high emotional labour. To sustain MHN resilience over time, future workplace resilience interventions could implement and test the impacts of resilience-inclusive clinical supervision approaches following the initial resilience programme. The study findings indicate that being proactive in supporting MHN in their stressful and challenging jobs is vital to addressing the health and well-being of the workforce, and supporting safe and therapeutic practice. Although the PAR programme provided MHN with further skills and resources to manage stress, this is only one strategy in a necessarily broader social–ecological approach to promoting structural as well as individual change to reduce workplace stressors and their impacts. As Masten and Obradovic (2006) cau-
F I G U R E 1 Strengthening nurses’ workplace resilience—a social– ecological approach
tion, understanding resilience to occur only through individual attributes can result in “victim blaming” if positive outcomes to adversity are not achieved. Without addressing the structural and systemic processes which impact nurses, resilience programmes alone are not a “magic bullet” (Masten & Obradovic, 2006) for achieving resilience
TA B L E 3 Social–ecological resources to strengthen nurses’ workplace resilience Profession
as they address only some of the interactional processes involved in overcoming adversity.
Collective professional identity Organization
This study is limited to MHN from one organization, most tings. They may not reflect the experiences of other MHN and
Safety initiatives Work unit
Clinical leadership
benefit from resilience programmes. Future studies could conspectrum of nursing roles, experience and seniority and in various mental health contexts.
Stigma reduction Managerial support
potential for new graduates and/or less experienced nurses to sider implementing resilience education with MHN across the
Clinical supervision & reflective practice Well-being culture
of whom were experienced clinicians working in inpatient setthe findings may not be transferable to other settings. There is
Well-being & support programmes
Positive team culture Individual
Resilience education Self-c are and self-compassion
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FOSTER et al.
includes provision of resilience programmes and the promotion of self-care and self-compassion. At the work unit level, this involves workplace cultural change including strategies to reduce mental illness-related interpersonal stigma between colleagues (Knaak, Mantler, & Szeto, 2017), developing clinical leadership including role modelling and mentoring (Ennis et al., 2013), managerial support for staff well-being (Cleary et al., 2014) and promoting a positive workplace team culture. At the organizational level, a culture and policy of workplace safety and violence reduction initiatives, and commitment to staff well-being, can drive and support change across the organization. Resilience-informed clinical supervision models can help sustain resilience over time. MHN are part of a wider profession, and at a professional level, a commitment to strengthening specialist MHN identity (Santangelo, Procter, & Fassett, 2018) can support the collective resilience of MHN as a group (Cleary et al., 2014). The health and well-being of nurses are also a professional responsibility. National support services such as the Australian Nurse & Midwife Support Service at https://www.nmsupport.org.au/ can provide external and confidential tailored support for nurses’ health and well-being.
7 | R E LE VA N C E S TATE M E NT This qualitative inquiry explored mental health nurses’ perspectives on a workplace resilience programme. Mental health nurses were able to strengthen their resilience through a process of understanding resilience, and applying cognitive and emotional strategies such as positive self-t alk, managing negative self-t alk, being aware of and managing emotions, and showing more empathy, to address workplace challenges. Resilience of the mental health nursing workforce is the responsibility of organizations and employers as well as individuals. Using a social–ecological resilience approach, mental health nurses’ resilience needs to be promoted at individual, work unit, organizational and profession levels.
AC K N OW L E D G M E N T S The project was funded by the Office of the Chief Mental Health Nurse, Department of Health and Human Services, Victorian Government. The authors acknowledge Brian Jackson, Director of Nursing, and the senior nurses who facilitated the programme.
E T H I C A L S TAT E M E N T The study was approved by the Melbourne Health Office for Research (LNR/16/MH/355 and QA2016160).
ORCID Kim Foster
http://orcid.org/0000-0001-6931-2422
Trentham Furness
http://orcid.org/0000-0002-3526-1687
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How to cite this article: Foster K, Cuzzillo C, Furness T. Strengthening mental health nurses’ resilience through a workplace resilience programme: A qualitative inquiry. J Psychiatr Ment Health Nurs. 2018;00:1–11. https://doi. org/10.1111/jpm.12467
