Resilience in Healthcare Settings

As we discussed in Chapter 7 (‘Resilience and Compassion’), resilience is ‘the ability to cope with adversity and to adapt to major life events’ (Jeamjitvibool et al., Reference Jeamjitvibool, Duangchan, Mousa and Mahikul2022; p. 2). Resilience ‘varies widely from person to person and depends on environmental as well as personal factors’ (p. 2). Resilience changes over time and is amenable to modification, adaptation, and enhancement. Resilience can be seen as a skill which it is possible to develop through careful effort and sustained attention.

Chapter 7 noted that, while a certain amount of resilience is helpful and even essential, resilience depends on not only the personal characteristics of each healthcare worker, but also the conditions in which they work. Relevant factors include the structure and function of teams, models of organisation, quality of leadership, and provision of resources. These matters have an enormous influence on individual experiences, attitudes, and behaviour, as well as the levels of resilience that are required and accessible in the workplace. Systemic challenges can include competing system demands, time constraints, inadequate resources, communication issues, poor emotional connections with the broader healthcare system, and the perception or reality of staff not being valued for the care that they provide.

It is likely that these themes will resonate with many people who work in large healthcare systems where organisational challenges can loom large, often distracting focus from day-to-day patient care. Chapter 7 concluded by indicating that mindfulness and meditation can help in navigating some of the challenges outlined and in building appropriate levels of resilience among healthcare staff.

The present chapter continues this discussion by exploring the relevance of resilience among healthcare workers during the Covid-19 pandemic (which occurred from 2020 onwards); outlining positive behaviours that promote individual physical health, mental health, and resilience; presenting a guided practice focusing on resilience and inner solidity; and drawing together the key themes of resilience, equanimity, and compassion towards the end of the chapter. The following chapter is devoted to ‘Building Compassionate Health Systems’ (Chapter 13) and looks at systemic factors that promote qualities such as mindfulness, awareness, resilience, and compassion in healthcare organisations.

At the outset, it is important to acknowledge that the term ‘resilience’ can be overused and misused. For example, the concept of individual resilience is sometimes invoked in order to place undue responsibility on individuals who experience stress, when the primary problem lies with systems of care or bureaucracies that place unreasonable demands on individual workers in the first place. Too often, employees are advised to attend resilience training, mindfulness classes, or compassion programmes solely so that managers do not have to deal with the fact that their policies and workplaces need to change. From this perspective, individual resilience is not always about coping with difficult situations. Sometimes, resilience means standing up against inappropriate demands and realising that the primary problem lies with the system and not with the individual, regardless of their level of individual resilience. The goal should be to create systems of care that care for all, without placing undue pressure on individual resources or individual resilience.

Resilience among Healthcare Workers During the Covid-19 Pandemic

The Covid-19 pandemic presented substantial challenges to the physical and mental health of many people, including healthcare workers. It was a significant test of resilience for populations as a whole and especially for frontline workers (such as clinical staff) who often operated in conditions of uncertainty and risk.

When the outbreak commenced in 2020, there was widespread concern about the impact of the virus and associated public health restrictions on mental health. Evidence soon showed that the combined effect of the Covid-19 pandemic and associated restrictions was that approximately one person in every five in the general population had significantly increased psychological distress (e.g., anxiety, depression) (Kelly, Reference Kelly2020). Particular risk factors included being female and living alone.

Rates of significant psychological distress among healthcare workers were approximately double those in the general population (Kelly, Reference Kelly2020; Liu et al., Reference Liu, Hou and Gu2022). To mitigate these effects, healthcare staff required several forms of practical support as a matter of urgency during the pandemic: careful rostering, the ability to take leave, and organisational support from employers. When necessary, they also required ‘psychological first aid’ to assist with managing risks that were both known and unknown, and challenges that deepened by the week. How did levels of resilience help in navigating these circumstances?

In 2022, Jeamjitvibool and colleagues published ‘a systematic review and meta-analysis’ of ‘the association between resilience and psychological distress during the COVID-19 pandemic’ (Jeamjitvibool et al., Reference Jeamjitvibool, Duangchan, Mousa and Mahikul2022). This research group found that, ‘during the pandemic, the higher an individual’s resilience, the lower the psychological distress. The results indicate that resilience is essential in promoting a person’s positive mental health and reducing negative consequences’ (p. 11):

During the pandemic, many healthcare professionals, other frontline workers, and members of the public demonstrated enormous resilience (Kelly, Reference Kelly2023). A sense of pride in their work likely boosted resilience among healthcare workers. In 2023, Hughes Spence and colleagues published ‘a narrative inquiry into healthcare staff resilience and the sustainability of Quality Improvement implementation efforts during Covid-19’ (Hughes Spence et al., Reference Hughes Spence, Khurshid, Flynn, Fitzsimons and Brún A2023). This group found that ‘the pride healthcare staff took from working throughout the Covid-19 pandemic was evident amongst the participants, alongside their resilience’ (p. 8):

Notwithstanding this and similar evidence of resilience, it is clear that many healthcare workers suffered deeply during the pandemic. It is also apparent that resilience was a key element in reducing such distress and managing uncertainty, but that resilience is best cultivated before such emergencies take place, as well as during them. With this in mind, there is a particular need for research ‘to look at ways in which resilient healthcare can be facilitated and supported in different practice settings, for example through the development of collaborative learning tools’ (Lyng et al., Reference Lyng, Macrae and Guise2022; p. 13).

Consistent with this observation, there is, over recent years, a growing literature on topics such as burnout and compassion fatigue among various healthcare workers (e.g., Sweileh, Reference Sweileh2020; Baqeas et al., Reference Baqeas, Davis and Copnell2021). But what can be done now to improve matters and boost resilience among healthcare workers? How can we use our current knowledge today to improve resilience, reduce burnout, and hopefully increase compassion in healthcare?

The remainder of this chapter focuses on individual-level actions to improve resilience and, thus, capacity for compassion, while the following chapter looks at system-wide factors and interventions that are needed at the level of organisations for greater compassion (Chapter 13: ‘Building Compassionate Health Systems’). For now, we start with positive behaviours that promote individual physical health, mental health, and resilience, followed by a guided imaginative practice focusing on resilience and inner solidity. The chapter will then conclude by drawing together its key themes of resilience, equanimity, and compassion in healthcare.

Building Physical and Mental Resilience as a Solid Basis for Compassion

Resilience and self-compassion find many of their roots in self-care. We cannot care for others unless we care for ourselves, so it is essential that healthcare workers pay attention to both physical and mental health. This includes actively considering levels of physical exercise, sleep patterns, dietary habits, and specific steps to improve mental health, both in our own lives and in relationship with other people. Physical and mental health are intimately related with each other. Both form the foundations for resilience and compassion.

Regular, moderate physical exercise enhances both physical health and mental wellbeing (Kelly, Reference Kelly2021). Humans were designed to move, so we function best when we have regular exercise as part of our lives. Most adults need to be physically active every day. Each week, we need at least 150 minutes of moderate intensity activity or 75 minutes of vigorous activity. We should also do some strengthening activities that work all our major muscles (legs, hips, back, abdomen, chest, arms, and shoulders) two or three days each week. Popular activities include running, cycling, swimming, brisk walking, various other sports, any other vigorous activities, and even energetic forms of dance. The key to establishing a regular exercise habit is that our chosen activities should be convenient, local, sustainable, and (ideally) enjoyable.

Sleep is also important for wellbeing. Most adults should aim to sleep for between seven and nine hours in every 24 hours. We can support good sleep hygiene by exercising in the morning (ideally outside); avoiding naps during the day (which can be challenging for shift workers); avoiding stimulants in the hours before sleeping (e.g., coffee, alcohol, cigarettes, sugar); enriching our diets with foods that contain tryptophan (e.g., chicken, turkey, milk, dairy, nuts, seeds); easing ourselves into sleep in the evening (i.e., dim lights, avoiding alcohol and screens, winding down gently); and keeping our bedrooms dark, cool, comfortable, and free of distractions (especially screens). Sleep merits more attention than we routinely give it. Good sleep is a valuable, free resource for wellbeing that most of us could mine more deeply.

From a dietary perspective, it is important to maintain a balanced diet in accordance with relevant guidance (Kelly, Reference Kelly2021). It helps if we de-link food from emotions, meanings, and self-esteem, and see food for precisely what it is: simply food. Certain nutrients, such as vitamin B12, can help with brain health, but a generally balanced diet will usually deliver all that our bodies need for physical and mental wellbeing. Eating is a routine behaviour, so it is wise to harness the power of habit to improve our eating patterns, and rationalise our ideas about food and weight. Radical diets do not work: they are unsustainable, unrealistic, and frequently ridiculous. Moderation and sustainability are the keys to positive eating and to reaping the benefits of good food for our bodies and minds.

Attending to our levels of exercise, sleep patterns, and dietary habits is an act of radical self-compassion which boosts health, enhances resilience, and empowers us to provide compassionate care to our patients and their families. It is also important that we pay specific attention to our mental wellbeing, even when everything seems to be going smoothly in our lives. Those are the times when we can really consolidate our psychological health, deepen our resilience, and resource ourselves for our challenging roles in healthcare.

In general, mental health improves when we realise that, too often, we equate activity with value, and frequently this is not the case. We inadvertently clutter our lives with unnecessary tasks and unneeded physical objects that weigh us down rather than move us forward. It is helpful if we consciously identify those aspects of our lives that truly help us to cultivate wellbeing, deliver value, and align with our intentions. To do this, we need to create mental space to maintain a calm focus on what matters. Specific techniques such as meditation and mindfulness can be useful as part of this broader commitment to conscious, value-based living. We can move away from unneeded activities and unnecessary objects, and towards our valued goals, once we identify them in this way.

Connecting with other people in a conscious and judicious way also helps with mental health. The first step is connecting better with ourselves by taking time to become more aware of our thoughts, moods, and emotions. As always, compassion for others starts with compassion for ourselves. This approach provides a solid basis for us to deepen, renew, and enrich the relationships we already have with partners, family members, friends, and colleagues. Being part of something bigger also matters deeply: families, book clubs, work groups, political movements. Reaching out is important because a growing sense of belonging nourishes our minds, even if we never explicitly draw on the support that certain groups or relationships offer. Finally, while connections matter deeply, it is also useful to disconnect at times, and to be alone: reading, walking, or simply being. For good mental health, we need both time together and time apart.

Most of us need to work harder on disconnecting from our devices: smartphones, laptops, and computers. This can be difficult, but small steps work best: leaving the phone in the kitchen at nighttime, minimising work emails outside working hours, and being compassionate with ourselves when we overuse our phones. We are human, social media is addictive, and change takes time. Minimising the negative impact of technology in our lives means making sustainable improvements to our habits. Radical change rarely works; incremental steps often do.

Once we have prioritised physical and mental health, and once we see this prioritisation as an act of radical self-compassion, what else can we do to boost our resilience and solidify the foundations for greater compassion towards other people and ourselves?

Cultivating Inner Solidity: Guided Imaginative Practice

Often, we lose sight of the resilience that we already possess. We forget the times when we were solid, strong, and compassionate in circumstances that were deeply challenging at the time. This is a pity. We are resourceful beings with extraordinary levels of adaptability. Too often, our previous strength moves to the back of our minds, and we are beset by the doubts, anxieties, and fears of the present moment. This guided resilience practice seeks to remind us of our core strength and re-connect us to the resilience that we already possess but do not always recognise when we need it, as seen in Box 12.1.

Resilience, Equanimity, and Compassion

So far, this chapter has explored relevant learnings from the Covid-19 pandemic in relation to resilience among healthcare workers. We noted that we cannot care for others, or become more resilient, unless we care for ourselves in the first instance. As a result, it is important that healthcare workers (and others) optimise our levels of physical exercise, develop positive sleep patterns, and improve our dietary habits, as best as possible.

Physical and mental health are intimately related to each other, so both require attention. Specific steps to improve mental health include seeking to maintain a calm focus on what matters (e.g., using meditation and mindfulness to deepen a commitment to conscious, value-based living), connecting with other people in a deliberate and judicious way (as well as disconnecting from family, friends, and colleagues when needed), and working harder to spend more time away from our devices (especially smartphones). Self-compassion also means forgiving ourselves when our best efforts falter, and simply trying again. Change takes time.

The guided resilience practice in the previous section of this chapter sought to remind us explicitly of our core strength and to connect us with the resilience that we already possess but do not always access when we need it. We are stronger than we give ourselves credit for.

The overall message from this chapter is that self-care is an act of radical self-compassion, is the basis of compassion for other people, and is a vital foundation for resilience. This is especially true when our jobs require a significant amount of compassion on a day-to-day basis. As Maddox and Barreto emphasise:

As individual healthcare workers, we can facilitate this process by building our own resilience (as best as is possible and reasonable in our circumstances), providing compassion to ourselves (through conscious, deliberate acts of self-care), and seeking to extend that compassion to other people, including our patients, their families, and our colleagues, as well as our own families and friends. These are challenging tasks, but they lie at the heart of healthcare.

In addition, it can be useful for healthcare workers to distinguish ‘safety’ from ‘safeness’, which is important because safety and safeness have different meanings and operate through different physiological systems:

In healthcare, there can sometimes be a relatively excessive focus on safety and a consequent lack of focus on safeness, especially in environments where staff do not feel supported by management. In mental health services, for example, staff who especially fear criticism can become risk averse and inadvertently add to patients’ feelings of emotional turmoil and lack of safety (Veale et al., Reference Veale, Robins, Thomson and Gilbert2023). Focusing on safeness and resources for compassionate care, rather than safety, can help to address this.

Equanimity is another important value throughout this process, as we seek to remain calm in the midst of the uncertainties of clinical decision-making and to navigate the vagaries of large healthcare systems in which many of us operate (Kelly and Feeney, Reference Kelly and Feeney2006; see also Chapter 2 of this book: ‘Background to Compassionate Healthcare’). It is not always easy to maintain balance and composure in these high-pressure environments, especially when faced with emotionally charged clinical scenarios. Consciously seeking to maintain equanimity can help with effective engagement with patients, clear thinking, better decisions, and optimal outcomes. Often, there is no definitive right answer to these clinical dilemmas, only the best provisional answer that can be generated at a given moment, to be reconsidered later.

Overall, a sense of equanimity promotes resilience. It allows us to optimise the balance between professional detachment and interpersonal engagement, which is so essential for effective, sustainable clinical practice. Equanimity also fosters a stable, thoughtful approach to healthcare, promoting compassion, benefiting patients, and supporting staff during challenging times. Resilience is a key factor in these situations too, including resilience at the individual level and resilience at the levels of teams, organisations, and entire health systems.

The next chapter explores systemic factors that can shape levels of equanimity, resilience, and compassion in healthcare. Both levels are important: resilience and compassion at the level of individual healthcare workers, and resilience and compassion at the level of organisations.