Understanding Professional Resilience

1. Understanding Professional Resilience Mrs Kathryn Gutteridge Consultant Midwife, Clinical Lead for Low Risk Care, Clinical Psychotherapist March 2014

2. Undermining Behaviours - champion Medical Midwifery • 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-and-exams/postgraduate-training/advice-and-support-trainees/assertiveness-work • 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. • Bullying has been cited as a major reason why many midwives leave the profession. • 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

3. Why do some clinicians manage and not others? Research Example Most clinicians come into a ‘caring profession’ to meet an unmet need within them. From a psychodynamic viewpoint it might be said that these individuals have some unconscious unmet element of their personality. 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. There has been a fair amount of research into this area within nursing and more so latterly within midwifery Midwives particularly work in a high stress and emotionally charged dynamic with the balance of care in two parameters: woman and fetus/baby. The Resilient Nurse: Empowering Your Practice Margaret McAllister, RN, MHN, BA, MEd, EdD; John B. Lowe, BSc, MPH, DrPH

4. Surviving and Thriving? Clinical Environments Negative Features of Large Bureaucracies • Rapid turnover • High pressure • Multiple conditions and pathology • 2 lives not one • Medico-legal perspective • Media interest in health ‘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’. • Uneven staff skill mix • Rapid staff turnover and instability • Work conditions are employer focused • Economics is the bottom line (consequences include widespread unpaid overtime) • Disparaging and rigid management • Controlling (leading to limited worker autonomy) Source: Adapted from Holmes (2006).

5. The Stress Diathesis Model 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).

6. Risk and Protective Factors in Children Risk Factors Protective Factors • 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 • 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).

7. Resilience Defining Resilience Another View Is…… • The concept of resilience refers to a person’s resistance to stress. • 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); • a process of adaptation to adversity (Newman, 2003); and a complex concept that combines individual, family, or organisational characteristics. • Resilience is a process of adapting to adversity that can be developed and learned.

8. Resilient Adults Aaron Antonovsky (1987) Sense of Coherence • Salutagenesis …. • Salus – health • Genesis - 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). • 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.

9. 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) • 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).

10. Developing internal Resources

11. Key Attributes Consistent with Resilient Individuals 5 Components

12. Finding a Way Forward Resilience & Health Professionals Practical Elements • Building positive professional relationships through networks and mentoring • Maintaining positivity through laughter, optimism, and positive emotions • Developing the emotional insight to understand one’s own risk and protective factors • Achieving life balance and using spirituality to give one’s life meaning and coherence • Becoming more reflective, which helps access emotional strength and assists in meaning making and thus, in transcending the present ordeal. 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.

13. 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.

14. Chart Adapted from Charney (2004).

15. References • 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. • 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. • 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. • Curtis. P, Ball. L, Kirkham . M. (2006) British Journal of Midwifery, Vol. 14, Iss. 1, 05 Jan 2006, pp 27 - 31 • Fontaine, K., & Fletcher, S. (2003). Mental health nursing (5th ed.). Upper Saddle River, NJ: Pearson. • Holmes, C. (2006). The slow death of psychiatric nursing: What next? Journal of Psychiatric and Mental Health Nursing, 13(4), 401–415. • 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. • McAllister. M; Lowe, J.B (2011). The Resilient Nurse: Empowering Your Practice, Springer Publishing: New York. • Marsh, D. T. (1996). Marilyn . . . and other offspring. Journal of the California Alliance for the Mentally Ill, 7(3), 4–6. • Newman, R. (2003). Providing direction on the road to resilience. Behavioral Health Management, 23(4), 42–43. • 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. • Rowland, J., & Baker, F. (2005). Resilience of cancer survivors across the lifespan. Cancer, 101(11 Suppl.), 2543–2548. • 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. • Segal, J. (1986). Winning life’s toughest battles (p. 130). New York, NY: McGraw-Hill. • Seligman, M. (1998). Learned optimism. New York, NY: Random House.