Critical Resilience for Nurses

An Evidence-Based Guide to Survival and Change in the Modern NHS

Michael Traynor

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317272489
• Edition: 1
• Topic: Médecine
• Subtopic: Prestation de soins de santé

The nursing profession is under pressure. Financial demands, student debt, the target culture, political scrutiny in the wake of major care scandals and increasing workloads are all taking their toll on professional morale and performance. This timely book considers the meaning of resilience in this adverse context and explains why measures to preserve individual nurses' and students' well-being are flawed if they don't take into account wider political and organizational perspectives.

Arguing that healthcare can be thought about and experienced differently, this book:

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• provides a summary of the latest research on resilience, explaining its relevance and also limitations for nurses;

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• considers debates about compassion and highlights the effects of policy agendas on nurse education and nursing work;

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• re-evaluates nursing's professional identity, including where nursing has come from and the effects of class, gender and race on its powerbase;

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• assesses the role of politics and social media, both in driving change and feeding resistance; and

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• introduces the idea of critical resilience as a complete framework for resisting bullying and fostering survival and change in the nursing workforce.

Direct, upbeat, at times provocative and witty, this agenda-setting book enables nurses to understand why they feel the way they do. It also lists what opportunities are available to them to change, resist and survive in what has become a complex, challenging – if still deeply rewarding – line of work.

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Chapter 1
Resilience: where did it come from?

Research on resilience and its use in nursing

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MICHAEL: Can you tell me the difference between a good clinical placement and a bad one?

PENNY (third-year Adult branch student): I’d say good is how the ward is run, so if it’s an organized ward, they know you’re coming; they know how to look after a student -

MICHAEL: Which is how?

PENNY: Making you feel welcome, supporting and teaching you, cause obviously we do placement for free, pretty much, if, like I’ve always said, if I go to a placement and they teach me, I’m not bothered that I’m not getting paid, because it’s a learning opportunity. But if I’m going somewhere and your mentor’s not even interested in you, none of the staff, they see a student as a burden, that is what makes a bad placement, for me anyway . . .

DAVE: Yeah, maybe it’s not about personality but it’s about that they are overwhelmed with work, so they are very nice people and very helpful, but, because they are overwhelmed by work and they are very stressed, they just don’t really bother about having us students, because they have six other patients to look after, so they don’t have time to look after the student.

In this chapter I set out some definitions of resilience. But definitions are of little help if you want to understand an idea. It is more useful to know where that idea came from or, in other words, how it got here. So I start by summarizing the origins of the concept and its development from studies of particular population groups through to investigations of resilience among nurses.

Origins of research into resilience: psychoanalysis and trauma

Few would argue today with the idea that childhood events have a lasting impact throughout adult life. But before Freud’s psychoanalytic theories¹ developed at the turn of the nineteenth and twentieth centuries such ideas would have been uncommon or at least not considered a subject worthy of scientific investigation. Because of Freud’s position – as a doctor attempting to treat patients with sometimes incapacitating problems – his focus was on psychopathology, literally the study of the suffering of the soul. Often suffering was related, he found, to traumatic events in childhood. His first patient who has come to be known as ‘Anna O’ found that talking about her symptoms freely and retrieving memories of traumatic incidents she had experienced led to some relief of those symptoms. From this practice Freud developed his ‘talking cure’ and an elaborate range of theories that he refined throughout his life. Fundamental to them is the notion of the unconscious, the continual repression of thoughts that are too difficult or traumatic to process consciously of which the individual is unaware yet which influence thought, emotion and behaviour. Freud was interested in the effects of trauma on the individual and their expression in talk and behaviour, sometimes in bizarre symptoms. Though based in extended and painstaking clinical work, his theories in many ways run counter to prevailing ideas and common sense. His work remains controversial.

The work of Freud and his colleagues provided a fertile ground for later psychological studies of childhood but the field became characterized by strong divisions and rival theories and approaches. Attachment theory developed by John Bowlby (1907–1990) emerged from and challenged Freud’s theories. Bowlby, whose own childhood was characterized by distant and interrupted relationships with his parents, focussed his work on the child’s early environmental experiences and found that separation from a primary care giver was often associated with trauma at the time and sometimes social and emotional problems in later life. Bowlby’s ideas, first presented in the late 1950s and early 1960s, caused anxiety among the followers of Freud. The key difference between them was that Bowlby’s focus was on observable events in the child’s upbringing while Freud and his followers believed that it was the events that occurred in the imagination of the child that provided the source of psychic problems. From the Freudian point of view, there is no way of telling from observing behaviour alone the meaning of that behaviour for the individual. We will return to this line of argument in Chapter 2. A second difference concerned focus. Bowlby developed a theory of child development that he claimed had the advantage that it was built on observation of the normal child rather than extrapolated from clinical work with already damaged individuals (Gullestad 2001). There are very many accounts of the origins of ‘resilience’ research and it is rare to find Bowlby mentioned in these but his theory of the benefits of attachment and his interest in the effects of childhood trauma coupled with his concern for direct observation of environmental events impinging on the child set the context for later studies.² Succeeding researchers have considered the presence of at least one healthy attachment to a significant adult as a precondition of resilience in children (Earvolino-Ramirez 2007).

James Anthony (1916–2014), one of the first child psychiatrists to write at length about the topic of resilience and vulnerability, collaborated with Bowlby as well as Anna Freud (daughter of Sigmund Freud) in his early career. Anthony saw the origins, or rather the forerunners, of research on human resilience in two areas. One, perhaps surprisingly, lay in laboratory experiments in which rats were placed in various types of extreme environments and observed to respond in very different ways, some ‘seemingly thrived on it’ (Anthony and Cohler 1987, p. 4). The second was epidemiological studies that had showed varied susceptibility to coronary heart disease in particular populations as well as the apparent capacity of some individuals to live through major social and other life changes ‘and yet exhibit little if any overt evidence of illness’ (p. 5). Anthony and others focussed on child development in conditions of social disadvantage and were fascinated by the same apparent ability of some children to survive disadvantage. They used the term ‘invulnerable’ in a possibly awkward attempt to label this phenomenon. Anthony himself drew some similarities between these ‘invulnerables’ and the detached and sociopathic character Meursault from Albert Camus’ 1942 novel L’Etranger (The Outsider). When Meursault’s mother dies, for example, he is mildly irritated rather than deeply affected. This gives an indication of Anthony’s nuanced approach to the notion of resilience. Anthony drew on Freud’s ideas of the psyche’s defensive structures that protect against the impact of strong external stimuli in his explorations of the individual’s response to its environment. However, for him, the most efficient protective system took the form of the infant’s caregiver and her (for many researchers the caregiver was generally the mother) actions and precautions.

In the years after Freud, some psychoanalysts chose to focus more on the role of the ego than on the unconscious forces at work in the individual, trying to shift the field away from psychopathology onto more positive ground. So it is not surprising that research into resilience came to emphasize the ‘coping’ work that the ego was considered to engage in (known as ‘ego-resilience’) rather than unconscious defences, although some claimed that the two worked in harmony together (Moriarty and Toussieng 1976). In addition, effective personal coping could take place in environments that were more or less encouraging of self-reliance and researchers also commented that there was ‘nothing out of the ordinary’ in such resilience-enabling situations. From observation, researchers began to develop inventories of the apparent characteristic behaviour of ‘good copers’ along with questionnaires designed to assess the presence of these factors e.g. (Murphy and Moriarty 1976).³ So to summarize this part of its history, early research on resilience paints a picture of internal and environmental factors that interact and change during developmental periods of children.

A debate develops: can resilience be grown?

One of the continuing debates among resilience researchers has concerned two related questions ‘Is resilience essentially a personal characteristic – a character trait – or a dynamic developmental process?’ (Earvolino-Ramirez 2007 p. 76). The second question flows from this: ‘and if it is a developmental process, can it be taught or improved by external intervention?’ I will talk more about how the second question played out later in this chapter. The more dynamic idea of resilience necessarily involves two components. The first is the adversity to which the individual responds. The second is the response, ‘rebounding’ or ‘reintegrating’ by returning to ‘normal life’, or ‘coping’. Some writers also add that the response involves a positive personal growth, similar to the popular idea that some types of people ‘thrive on adversity’.

Researchers focussed their work on identifying sources of vulnerability on the one hand and on the other protective factors that could modify the harmful impact of adverse circumstances. It is important to remember that the flavour of this research is largely a result of its focus on children and young people growing up in some kind of disadvantaged background. In this context, vulnerability might include having parents with a mental health problem, living in a poor urban neighbourhood or low intelligence. Researchers began to produce lists of ‘protective factors or processes’ though some were at pains to point out protective factors are contextual, situational and individual and lead to varying outcomes (Johnson and Wiechelt 2004). For example, both vulnerabilities and protective factors can be perating at the community, family or individual level (Luthar and Cicchetti 2000). At each of these levels supportive relationships with adults in school, emotionally responsive family caregiving and an easy-going temperament could be considered protective. Nevertheless despite the complicated way that these protective factors might interact with other elements of context, researchers devised questionnaires aimed at measuring the presence of such factors. For example, the Resilience Scale for Adults is a questionnaire with 37 questions designed to assess what the authors believe are the five dimensions of resilience: personal competence, social competence, family coherence, social support and personal structure (Friborg et al. 2003). The scale was devised based largely on the lists of protective factors developed by some of the preeminent resilience researchers over the previous 20 years and was created specifically to measure the presence of these attributes (Friborg et al. 2003). Other researchers have produced summaries of the protective factors labelled by six of the major resilience researchers. One lists 28 personal characteristics or skills, for example ‘good natured, easy temperament’ and ‘decision-making ability’ (Earvolino-Ramirez 2007). The single factor that relates to the individual’s context, ‘informal social support network’, is assessed by asking the individual to rate it so there is an almost total focus on the indi vidual.

Even though it could be said that by 2000, the ‘dynamic’ view of resilience had won the day, in the years leading up to this some researchers downplayed the contribution of social and environmental factors to resilience on the grounds that it is difficult to distinguish between the positive and negative effect of the same kind of social relationships (a marriage can be sup portive but a divorce is likely to be threatening) and focus on internal pro tective factors instead (Rutter 1985). Perhaps these investigators felt that their skills and training equipped them better to investi gate and measure the so-called internal world of individuals – anxiety, personality, IQ, etc. – rather than the messy and uncontrol lable world of social relations and environmental contexts.

Some researchers have been at pains to point out dangerous misconceptions and simplifications of the idea of resilience that may arise as it is communicated from scientists to the public and to policymakers. The key, they emphasize, is the argument that resilience is not a personal characteristic of the individual but a term that might be applied to developmental trajectories, or in other words:

many characteristics that appear to reside in the child are in fact continually shaped by interactions between the child and aspects of his or her environment.

(Luthar and Cicchetti 2000 p. 864)

They explicitly raise the danger of policymakers falling back on common sense ideas of resilience as a kind of ‘exceptional sturdiness’ and of politicians misunderstanding or misusing the ideas raised by resilience research to blame vulnerable individuals for not possessing this ability and therefore reducing social support to these groups (Luthar and Cicchetti 2000 p. 864).

Not all researchers have been as clear-minded about these potential hazards. Consider these two statements by researchers about the importance of resilience research relative to broader social programmes:

Some sources of adversity are preventable such as child maltreatment and it is far more effective to try to prevent these in the first place.

(Masten and Obradovic 2006)

The primary concern of those working with children and adolescents at risk is the prevention of maltreatmen...