Title. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review
Aim. This paper is a report of a literature review to explore the concept of personal resilience as a strategy for responding to workplace adversity and to identify strategies to enhance personal resilience in nurses.
Background. Workplace adversity in nursing is associated with excessive workloads, lack of autonomy, bullying and violence and organizational issues such as restructuring, and has been associated with problems retaining nurses in the workforce. However, despite these difficulties many nurses choose to remain in nursing, and survive and even thrive despite a climate of workplace adversity.
Data sources. The literature CINAHL, EBSCO, Medline and Pubmed databases were searched from 1996 to 2006 using the keywords ‘resilience’, ‘resilience in nursing’, and ‘workplace adversity’ together with ‘nursing’. Papers in English were included.
Findings. Resilience is the ability of an individual to positively adjust to adversity, and can be applied to building personal strengths in nurses through strategies such as: building positive and nurturing professional relationships; maintaining positivity; developing emotional insight; achieving life balance and spirituality; and, becoming more reflective.
Conclusion. Our findings suggest that nurses can actively participate in the development and strengthening of their own personal resilience to reduce their vulnerability to workplace adversity and thus improve the overall healthcare setting. We recommend that resilience-building be incorporated into nursing education and that professional support should be encouraged through mentorship programmes outside nurses’ immediate working environments.
Workplace adversity is an issue gaining increasing attention in the international nursing literature. A great deal of literature attests to the industrial and organizational challenges currently facing nurses in many parts of the world. Even a cursory glance at this suggests that nurses are under siege in the workplace, and are facing a whole range of problems and challenges as they go about their work. These difficulties include widespread shortages of experienced nurses, an ageing workforce, increased use of casual staff in the nursing workforce, bullying, abuse and violence, issues around professional autonomy, imposed organizational change, occupational health and safety issues and constant restructuring (Jackson et al. 2001, Cline et al. 2003, Strachota et al. 2003). These (and other) challenges have been associated with problems in retaining a viable nursing workforce because they contribute to a working environment that can be experienced as hostile, abusive or unrewarding (Jackson et al. 2002, Strachota et al. 2003).
Although many nurses leave the healthcare system because of issues associated with workplace adversity (Cline et al. 2003), others remain. Of those who remain, some experience stress-related difficulties such as burn out (McVicar 2003, Strachota et al. 2003). However, others survive and even thrive within very demanding organizational situations, and succeed in the face of the same on-going challenges and constraints that are associated with the retention problems currently facing nursing (Tedeschi & Calhoun 2004). This raises the question of why some nurses are able to thrive and continue to find satisfaction with their careers despite the current challenges and problems, while others are not. We suggest that some nurses are more personally resilient than others and are better able to cope with workplace adversity.
The aim of the literature review was to explore the concept of personal resilience as a strategy for responding to workplace adversity and to identify strategies to enhance personal resilience in nurses.
A search of computerized databases CINAHL, EBSCO, PubMed and Medline was carried out. Search terms included ‘resilience’, ‘resilience in nursing’, ‘and workplace adversity ‘together with ‘nursing’. Papers were selected for inclusion if they met the aims of the review, were available in English, and published between 1996 and 2006. Additional papers that did not come to light in the initial literature search were obtained through an examination of reference lists of published papers. Each paper was read and key ideas identified. Regular meetings were held to discuss emergent ideas, common themes, and how these might be applied to workplace adversity in nursing. Subsequently, a number of strategies for developing personal resilience in nurses were identified.
The initial literature search generated 70 papers, with a further six included from the examination of reference lists.
Papers were appraised for suitability, relevance and trustworthiness of material by the authors who subsequently included 50 papers in the review.
Exploring the concept of resilience
Progression of resilience as a concept extends from the 1800s and continues to the present time. During its conceptual development, resilience has been constructed as a trajectory, a continuum, a system, a trait, a process, a cycle, and a qualitative category (Flach 1980, 1988, Rutter 1985, Jacelon 1997, Tusaie & Dyer 2004, Bonanno 2004, 2005). Rutter (1985) proposed a continuum with vulnerability and resilience at either end. Another perspective highlights a model of resilience that identifies two stages – integration and reintegration (Flach 1980, 1988). Tusaie and Dyer (2004) cite the value of resilience in dealing with stressful life transitions. In theories of resilience as a trait, much attention has been given to the idea that a combination of physical and psychological characteristics, including body chemistry and personality factors, give individuals the skills to be resilient (Jacelon 1997).
From a historical viewpoint, there are two major discourses of resilience – the physiological and psychological (Tusaie & Dyer 2004). Physiologically, human beings have homeostatic mechanisms to foster resilience in the event of adversity such as haemorrhage or stress (Rabkin et al. 1993). Psychological resilience is defined as the capacity to move on in a positive way from negative, traumatic or stressful experiences (Tugade & Fredrickson 2004). Bonanno (2004) notes that resilience can be differentiated from recovery in that recovery from an event means that there is a period in which normal functioning is suspended, whereas resilience involves maintenance of equilibrium, with no loss of normal functioning.
Resilience has attracted the attention of scholars for years; yet, a common definition has proved elusive. While most authors agree that it is the ability to grow and move forward in the face of misfortune, much ambiguity continues to exist surrounding the underlying processes that comprise resilience, and some have argued for greater clarity in the use of definitions (Polk 1997, Luthar & Cicchetti 2000, Coleman & Ganong 2002). However, Rutter (1999) argues, the concept of resilience has been constructed broadly and that this is necessary and appropriate.
Resilience is sometimes defined according to qualities, traits or characteristics rather than in a neat and contained definition. For example, Giordano (1997) lists qualities associated with resilience such as resourcefulness, self-confidence, curiousness, self-discipline, level-headedness and flexibility. She also highlights the importance of emotional stamina and problem-solving. Similarly, Jacelon (1997) suggests that resilient individuals are generally intelligent, with a strong sense of self. Tugade and Fredrickson (2004) draw a metaphor between resilience in individuals and the elasticity and malleability of certain metals. In illustrating this metaphor, they highlight the differences between brittle and malleable metals, likening the properties of these malleable metals to the psychological qualities in some individuals that allow them to withstand strain and hardship.
Definitionally, resilience is positioned interdependently from adversity – to demonstrate resilience, one must first encounter adversity. Coleman and Ganong (2002, p. 1) define resilience as ‘a dynamic process encompassing positive adaptation within the context of significant adversity’, while Rutter (1999, p. 119) describes it broadly as ‘the phenomenon of overcoming stress or adversity’.
As a response to identified inconsistencies in understandings of resilience, Polk (1997) examined 26 published papers to identify characteristics or themes that distinguish and define resilience. From this, she was able to identify four patterns of resilience: dispositional pattern, which encompasses psychosocial attributes; relational pattern, which refers to intrinsic and extrinsic roles and relationships influencing resilience; situational pattern, which captures the ability people have to assess and react to stressors or situations of adversity; and the philosophical pattern, which includes personal beliefs and principles (Polk 1997). Furthermore Polk, agrees with Giordano (1997) in stating that problem-solving is an essential strategy to the survival of the individual.
For the purposes of this paper, we refer to resilience as the ability of an individual to adjust to adversity, maintain equilibrium, retain some sense of control over their environment, and continue to move on in a positive manner. It is therefore an active process that Giordano (1997, p. 1032) describes as ‘a shifting balance between vulnerability and resilience’. If equilibrium is maintained, an individual can theoretically manage any situation that comes along. Thus, we argue that developing personal resilience can reduce vulnerability.
Vulnerability and workplace adversity
Notwithstanding the various perspectives and positions held in relation to resilience, two-key related concepts are visible in the literature. These are vulnerability and adversity. Some authors place resilience and vulnerability on opposite ends of a continuum, such that responses are dependent on several protective mechanisms and interactive processes (Rutter 1985). Vulnerability, or susceptibility, is seen in opposition to resilience (Kulig 2000). However, it has been noted that there is inconsistency and little consensus about the term vulnerability itself (Luthar & Cicchetti 2000).
Adversity is the state of hardship or suffering associated with misfortune, trauma, distress, difficulty, or a tragic event (Rutter 1999, Luthar et al. 2000, Tugade & Fredrickson 2004). Workplace adversity can be viewed as any negative, stressful, traumatic, or difficult situation or episode of hardship that is encountered in the occupational setting.
Previous uses of the concept
Psychologists have led the way in exploring the concept of resilience, and have given most attention to this construct in relation to children, adolescents and families (Jacelon 1997, Hunter & Chandler 1999, Coleman & Ganong 2002). In the child development literature, resilience is associated with the achievement of favourable outcomes and positive personality attributes among children experiencing life adversity. Early research with children of women with schizophrenia identified childhood resilience as an important theoretical and empirical area of study (Luthar et al. 2000). Further research on childhood resilience was conducted with a broader population and including a wider range of adversity, such as poverty, chronic illness, traumatic events, child abuse and neglect (Luthar et al. 2000). Mentoring programmes for children and young people have also been explored (Gilligan 1999, Benard & Marshall 2001, Laursen & Birmingham 2003), with evidence that caring relationships have the power to protect healthy development in children at risk (Benard 1991). Resilience research has expanded to include ‘educationally’ or ‘academically’ resilient children. This encompasses those who succeed in school despite social stresses such as poverty and abuse (Kitano & Lewis 2005).
In adolescence, the focus has been on those at risk of psychosocial problems. For example, adolescents who have been incarcerated are at extreme risk of poor outcomes. Todis et al. (2001) discuss internal and situational factors that account for differences among adolescents returning to their communities from youth correctional facilities. Others have explored resilience in youth homelessness (Rew et al. 2001). Ahern (2006) found, from a review of the literature, that resilience in adolescence is constructed as a composite of attributes that include personal characteristics, sources of social support and available resources.
Contrary to the findings of the majority of resiliency research, Hunter and Chandler (1999) question whether resilience in ‘at risk’ youth is a healthy state. In their study, adolescents reported themselves as resilient, which meant for them being disconnected (do not trust others), isolated (do not have support) and insulated (from emotional pain). These adolescents reported that they only had themselves to rely upon. Hunter and Chandler (1999, p. 246) suggest that ‘resilience in adolescence may not be an adaptable, flexible, competent process of overcoming adversity but a process of defence’.
In the 1970s, when looking at outcomes for people with schizophrenia, researchers noted that those achieving better outcomes had high levels of premorbid functioning and, although not named as such, Luthar et al. (2000, p. 544) suggest that ‘these aspects of premorbid social competence might be viewed today as prognostic of relatively resilient trajectories’. Other studies of resilience in adults have included men with HIV/AIDS, women with chronic illness (Schaefer 1995, Asbring 2001, Motzer et al. 2003), people with cancer (Jacelon 1997), transition from hospital to home (Esche & Tanner 2005) and people experiencing severe trauma and loss (Bonanno 2004).
The concept of resilience has also been discussed from the perspective of building family strengths (Darbyshire & Jackson 2005). When used in relation to families, resilience describes the ability of a family to carry on in the face of adversity (Silberberg 2001). Effective parenting is viewed as a major variable that has the potential to mediate the risk effects in children (Coleman & Ganong 2002). Barnes (1999) explores the impact of divorce on children and parents and factors that promote resilience and family functioning.
Patterson (2002) considers ‘families’, as a social system, to be resilient in ways that parallel individual resilience. Emphasis is placed on a family’s subjective appraisal of their sources of stress and their ability to manage these. Two perspectives dominate the discourse: exposure to significant risk as a prerequisite for being considered resilient and promotion of strengths for all families in which life in general is viewed as risky. Moreover, Joinking (2003) focuses on providing support services and fostering resilience to help individuals and communities strengthen and increase their capacity to help themselves. Thus, at individual, interpersonal and communal levels, people, their families and the community can be viewed either as vulnerable or as resilient.
Awareness of the benefit of resilience to organizations as well as staff has recently surfaced through studies on positive dispositions (Shirom 2004, Harvey et al. 2006) for teachers (Gu & Day 2006), mental health clinicians (Edward 2005) and nurses (Judkins et al. 2005, McGee 2006). Nurses have a particular interest in resilience because they help people and families in dealing with adverse situations (Jacelon 1997, Polk 1997). Nurses have contributed to the discourses on resilience in diverse areas including adolescent resilience (Hunter & Chandler 1999), strategies for developing resilience in nursing students (Hodges et al. 2005, Judkins et al. 2005), nurse case managers (Bright 1997), operating theatre nurses (Giordano 1997), community resilience (Kulig 2000), and theoretical development of the concept of resilience (Jacelon 1997, Polk 1997, Tusaie & Dyer 2004).
Resilience in nurses
Nurses bear witness to tragedy, suffering and human distress as part of their daily working lives and, because of the stressors associated with assisting others to overcome adversity, resilience is identified as essential for nurses in their everyday work (Tusaie & Dyer 2004). Building resilience based on the Human Becoming School of Thought [HBST] (Parse 1998) has the potential to assist nurses in dealing with the workplace adversity associated with interpersonal difficulties, resource problems and other workplace problems that have widely been acknowledged in the nursing literature. Parse’s (1998) theory places importance on directing health choices for quality of life. Hodges et al. (2005) consider resilient nurses an essential element in an ever-changing healthcare system. They challenge nurse educators ‘to better prepare nurses for sustained professional resilience’ (p. 548) by ‘teaching strategies of reflective learning and reflexive practice’ consistent with the practice of HBST (p. 551).
Bright (1997) and Giordano (1997) suggest that building personal resilience is a means for nurse case managers to cope with the stress associated with their work. Further, Bright (1997) noted that although nurses spend a great deal of time and effort caring for others, they show little evidence of self-care; therefore, she promotes a self-care approach to building personal resilience. McGee (2006) explored her own resilience as a nurse in an emergency shelter for homeless men. She proposes that resiliency is widespread but largely unrecognized within nursing, and comments that without resilience she herself would have long as abandoned her profession for a less taxing career.
Resilience and retaining nursing staff
As with literature on building family strengths (e.g. Darbyshire & Jackson 2005), resilience can be applied to building the strengths of nurses as individuals and collectively. In a similar vein to the discourses surrounding family resiliency, rather than suggesting that resilience in nurses must be underpinned by exposure to significant risk as a prerequisite for being considered resilient, the focus should be on the promotion of strengths for all nurses for whom the workplace is viewed as risky. Hodges, et al. (2005) agree that resilience can be developed and may help retain nurses in the profession, rather than abandoning their career path when the complexities of providing health care seem overwhelming.
McGee (2006) proposed the need to promote personal growth in nurses because it is not possible for them to give patients what they do not themselves possess. This may explain why nurses, feeling burnt out, agonize over abandoning the healthcare system rather than perhaps improving or changing their position, and may be the reason that retaining nurses in the profession can be so difficult. McGee (2006) suggests it is nurses’ own resiliency skills that sustain them through challenging and difficult working climates.
Strategies for strengthening personal resilience in nurses
Although the discussion on resilience as being innate or learned still continues in some quarters (e.g. Makikangas et al. 2004, Kelley 2005, Harvey et al. 2006), we believe that individuals can develop and strengthen personal resilience through developing strategies for reducing their own vulnerability, and the personal impact of adversity in the workplace. Tugade and Fredrickson (2004) suggest that everyone has resilience potential, but its level is determined by individual experiences, qualities, the environment and by each person’s balance of risk and protective factors. Protective factors help individuals to achieve a positive outcome regardless of the risk (Tusaie & Fredrickson 2004).
It is important to assist nurses to develop skills that will aid them in being more resilient and better able to cope with and protect themselves from the effects of workplace adversity. A growing body of evidence suggests that the personality trait of hardiness helps to buffer or neutralize stressful events or extreme adversity (Collins 1996, Judkins et al. 2005). Hardiness has been described as having three dimensions:
...being committed to finding meaningful purpose in life, the belief that one can influence one’s surroundings and the outcome of events, and the belief that one can learn and grow from both positive and negative life experiences (Bonanno 2004, p. 25).
The literature supports the notion that hardiness can be learned. Judkins et al. (2005) measured hardiness attributes in a cohort of students before and after undertaking a nursing administration programme. Positive changes in hardiness mean scores were verified by qualitative findings, which revealed important changes in skills related to all three elements of hardiness. In addition to hardiness, Bonanno et al. (2002) discusses self-enhancement, repressive coping, positive emotions and laughter as being resilience-promoting. Tugade and Fredrickson (2004) suggest that the ability to find positive meaning in adverse situations and to regulate negative emotions contributes to personal resilience. Furthermore, they found that positive emotions assist resilient people to recover from negative emotions. They conclude that positive emotions could potentially assist in building resilience and provide a buffer against life adversity (similarly Bonanno 2004, 2005). However, they identify a need for further research to explore whether frequent, repetitive experiences of positive emotions can contribute to strengthening personal resilience (Tugade & Fredrickson 2004). Fredrickson (2004), noting psychological resilience as an enduring personal resource, suggests that experiences of positive emotions in the long-term build psychological resilience rather than just reproducing it. She proposes that positive emotions broaden a person’s initial thought-action inventory, increasing thoughts and possible actions that come to mind when faced with an adverse situation. Through adaptation the individual develops a greater range of resources, which increases personal resilience.
In her examination of resilience as a tool for nurse case managers, Bright (1997) provides a list of elements of resilience. She identifies optimism as a key component and in this way concurs with Tugade and Fredrickson (2004) in identifying positive emotions as important. In addition to optimism, Bright associates factors such as autonomy, empowerment, emotional awareness and self-care as important in developing resilience. Giordano (1997) also promotes self-development as the key to strengthening personal resilience. McGee (2006) concurs and proposes that nurses care for ‘the self’ through sharing experiences of vulnerability and resilience. She suggests using reflective journaling techniques and postclinical discussions to provide opportunities for growth and sharing. Hodges et al. (2005) also advocate reflective journaling and further support the notion of acknowledging and praising success in nurses’ achievements to promote feelings of pride which help build resilience.
The nature of workplace adversity for nurses may involve interpersonal difficulties such as feeling bullied or oppressed, blamed and scapegoated or devalued in some way (Jackson et al. 2001, Hutchinson et al. 2006). These (and other) work-based interpersonal problems can be emotionally hurtful and, over time, can be deleterious to nurses and affect the ability of the profession to retain nurses.
We propose specific self-development strategies that can help build personal resilience to workplace adversity, particularly adversity grounded in interpersonal problems:
- • Building positive nurturing professional relationships and networks.
- • Maintaining positivity.
- • Developing emotional insight.
- • Achieving life balance and spirituality.
- • Becoming more reflective.
Building positive nurturing professional relationships and networks
Social support has been identified as a significant component in resilience, and the maintenance of relationships is a component of social support (Tusaie & Fredrickson 2004). Building positive professional relationships is crucial for nurses. This is the network that becomes a professional support system. We each need a network of people who can be called upon for guidance and support when needed. It is especially important to develop networks with people outside the immediate work area. These colleagues can provide validation and take on the role of ‘sounding board’, especially at times when tensions are running high in the workplace and when seeking such support within their own workplace may expose individuals to unnecessary vulnerability.
Professional networks should include relationships that are nurturing in nature. Ideally, all collegial relationships would have some degree of nurturing but this is often not the case. Everyone needs to be nurtured sometimes and it is important to foster these nurturing relationships. Actively seeking particular relationships, such as a mentoring relationship, can provide nurses with the opportunity to enter into mutually beneficial supportive and nurturing relationships (Daly et al. 2004).
Mentorship has been alluded to in the literature in relation to building healthy relationships to protect children at risk and promote resiliency (e.g. Gilligan 1999, Benard & Marshall 2001, Joinking 2003). From the perspective of nursing, McGee (2006) notes the benefits of guidance and support from colleagues and the need to nurture traits of resiliency in the self, students and co-workers.
By definition, adversity is not a positive phenomenon. However, adversity and hardship often do have some positive aspects. Resilient people are able to draw on some form of positive emotion even in the midst of stress and hardship (Fredrickson 2004, Tugade & Fredrickson 2004). Optimism and the capacity to see the range of future possibilities that events carry with them are aspects of maintaining a positive outlook (Bright 1997). Resilient people are able to see the positive aspects and potential benefits of a situation, rather than being continually negative or cynical. Positive emotions and laughter are associated with beneficial physical and emotional outcomes (Tugade & Fredrickson 2004), and Bonanno (2004, 2005) suggests that positive emotion and laughter can lessen levels of adversity-related stress by reducing negative emotions.
Developing emotional insight
There is increasing literature on the importance of emotional intelligence (EI) in the workplace. In broad terms, EI is the ability to understand one’s own emotional needs, and have insight into the emotional needs of those encountered in the workplace (Daly et al. 2004). Understanding one’s own emotional needs and reactions gives insights into how to cope with stress and adversity and can help spawn ideas for different ways of coping in the future (Bright 1997, Giordano 1997). Furthermore, as discussed earlier, positive emotions can assist in developing resilience (Fredrickson 2004, Tugade & Fredrickson 2004), and so developing insight into negative and positive emotions could be a beginning step in strengthening personal resilience. Giordano (1997) suggests journaling and self-reflection as strategies for enhancing emotional insight, as does McGee (2006).
Achieving life balance and spirituality
A number of writers describe the importance of feelings of connectedness, achieving life balance and having an ‘anchoring force’ in life (Giordano 1997, p. 1033). Tusaie and Fredrickson (2004) acknowledge the importance of ‘a belief system that provides existential meaning, a cohesive life narrative and an appreciation of the uniqueness of oneself’ (p. 4) for having high levels of resilience. Regardless of spiritual beliefs, it is important to participate in a range of healthy activities outside one’s professional life. These activities should ideally include those that are physically, emotionally and spiritually nurturing. In this way, it is possible to retain some balance in life, even when occupied in a very demanding career such as nursing.
Becoming more reflective
Theories of adult learning recognize the importance of reflection to learning (Larson & Brady 2001, Wilson & Kiely 2002). Reflection is a way of developing insights and understandings into experiences, and of developing knowledge that can be used in subsequent situations. In reflection, concrete experience is used as a catalyst for thinking and learning. Journaling can be a useful reflective strategy (Giordano 1997). Writing about an experience is known to be useful, in that the writer ascribes meaning to events (Jackson 2000). Thus, new understandings and insights can arise for the writer through the act of writing. For example, experiencing consistently negative emotional responses about a person, place or thing can be very illuminating, and may be a catalyst for reflection and exploring ways of adopting more positive responses to particular situations, people and events.
We believe that it is not only possible but favourable to build resilience as a strategy for assisting nurses to survive and thrive. Nurses’ occupational settings will always contain elements of stressful, traumatic or difficult situations, and episodes of hardship. Therefore, combating these adverse effects through minimizing vulnerability and promoting resilience has the potential to impact positively on nurses’ daily experiences.
Consequently, a qualitative study of nurses who have successfully remained in nursing could be undertaken to identify to what they attribute their personal resilience. This would build on existing knowledge of the impact of resilience in the workplace and augment known strategies of resilience building. Further, research to explore the characteristic elements of resilience and how they can be developed in nursing staff to reduce vulnerability to adverse work environments and promote self-care and development for nurses would be beneficial.
Although there is still much to be learned about how individuals meet and adapt to adversity and stressful life events, enough is known to recognize that building personal resilience has the capacity to assist nurses to survive and thrive in their work environment. Internationally, nursing is facing a range of challenges and difficulties which are attributed (at least in part) to workplace adversity. It is timely to explore innovative ways of nurturing and supporting nurses so that they are better able to thrive and sustain satisfying careers even in contexts of organizational difficulty and workplace adversity.
DJ was responsible for the study conception and design and DJ and ME were responsible for the drafting of the manuscript. DJ, AF and ME performed the data collection and DJ and AF performed the data analysis. ME provided administrative support. DJ and ME made critical revisions to the paper.