Develop skills to overcome daily challenges and prepare for the future.
- Burnout has been identified as a public health crisis, negatively affecting individuals, organizations, patient, and communities.
- Enhanced personal resilience should be combined with efforts to build resilient teams to effectively address the root causes of moral distress and burnout, which often stem from organizational/systems failures and/or ineffective leadership.
- Personal resilience can be developed to enhance the individual nurse’s ability to cope with the challenges of a stressful and chaotic healthcare environment.
AS A NEW RN, I was excited, hopeful, and passionate about entering the nursing workforce. I had performed well in my undergraduate program and I chose a job that took me away from my home, living alone for the first time. But it didn’t take long to realize that the world of nursing wasn’t what I experienced as a student. In fact, the realities of the profession hit hard during those first few months. I didn’t receive subtle hints of a radically different culture, but rather, overt messages from nurses at all levels, loudly welcoming me to the “real world.” I left the job after 1 year because of the cumulative effects of transition stress, loneliness, incivility, and my own immature coping skills.
I returned home and took a job where I was sure I’d be welcomed with open arms because I’d worked there and spent many clinical hours as a student. I loved the work I was doing and believed I was making a difference in our patients’ lives, but I soon realized that the toxicity I left behind was present in my new workplace, too. One day, a young physician I had come to know and trust told me that I needed to “stop caring so much” or I’d “never survive.” I reflected on this for several days and realized that I wasn’t willing to sacrifice my personal values, morals, or ethics to just survive. In fact, I took it as a challenge and vowed to prove him (and others) wrong. I promised myself that I would one day make a difference for other new nurses so that they wouldn’t have to join the ranks of the distressed, cynical, and burned out.
That moment, over 30 years ago, was the beginning of my journey of self-reflection, personal transformation, and a commitment to help others claim their joy, unabashedly demonstrate compassion in all encounters, and have the courage to stand up and speak out against workplace injustice.
Most of my career has been spent exploring the experiences of nursing students, new graduate nurses, and nursing professionals to learn how we can improve their ability to navigate the profession and healthcare environment. Through this process, I’ve come to focus my work on resilience, beginning with increasing personal resilience to survive and thrive as a professional nurse.
Resilience is a hot topic. It’s widely defined and broadly described, but most agree that it’s a positive attribute that’s valuable during and after adversity, crisis, or transition. You may be familiar with an older description of resilience: The ability to bounce back, typically from a negative life event, so that you return to a previous state of being. However, most definitions now focus on positive growth or enhanced development that occurs in an individual, team, or system because of difficulties, rather than in spite of them. In other words, a positive change occurs as a result of adversity, leading us to develop knowledge, skills, or attitudes that improve our ability to withstand future challenges, usually accompanied by an enhanced state of well-being.
Personal resilience, however, is not a panacea for all of the stressors and challenges we face. Bigger issues (including organizational climate and ineffective leadership) can lead to moral distress, burnout, and other negative outcomes, including nurse suicide. (See The consequences of moral distress and burnout.) These problems are pervasive within healthcare and are too big to place on individuals’ shoulders. They require moral courage and collective action through the development of resilient teams.
The consequences of moral distress and burnout
Moral distress and burnout are common among nurses.
Moral distress occurs when we’re expected to act in ways that go against our personal values, beliefs, morals, or ethics. Most frequently, these expectations come from rules, regulations, or authority figures that force us to choose between doing what’s right and complying with the expectations of our role or job. When we’re forced to choose policies over people, rules over relationships, and the corporate bottom line over compassion, we experience moral distress, which contributes to:
• negative health outcomes.
Burnout is characterized by cynicism, emotional exhaustion, and a lack of commitment to work. It’s been identified as a public health crisis that dramatically reduces the quality and safety of patient care. The effects of burnout have been linked to increased:
• medical errors
• mortality rates
• medical malpractice
• healthcare-associated infections.
Burnout also can lead to decreased:
• patient satisfaction scores
• interprofessional teamwork
• nurses’ job satisfaction
• employee effort and productivity.
The costs of burnout aren’t restricted to the organization, but also impact many clinicians’ personal lives, resulting in increased incidences of depression, substance abuse, and suicidal ideation.
Developing personal resilience
Personal resilience can be defined as an individual’s use of personal protective factors (PPF) to navigate stressful situations or perceived adverse events to effectively cope and reach a higher level of well-being, while enhancing the ability to face future challenges. PPFs are behaviors or characteristics (coping skills)—such as hope, faith, optimism, self-awareness, flexibility, humor, social support, and perseverance—that help buffer the negative effects of stress. (See What are your PPFs?) Developing and enhancing our PPFs strengthens our efforts to successfully handle adversity and improve well-being. Resilience often results in personal growth that wouldn’t have occurred without the adversity.
My desire to fully understand the concept of personal resilience led me to working with Holocaust survivors. These individuals have graciously welcomed me into their lives to share their stories of survival during one of history’s darkest times. I’m grateful for their willingness to share the details of their lives in the ghettoes and concentration camps and their experiences after the war. These individuals can be considered highly resilient because they demonstrate behaviors and attitudes that provide examples of the PPFs we want to develop in ourselves. These survivors’ stories may be extreme examples of tragedy and adversity, but they can teach us how to change our own responses to stress and challenges.
The 4Ps of resilience
PPFs are our tools for facing adversity, so to strengthen our efforts, we want to develop and enhance those we lack. I like to use the example of stretching a thin rubber band as far as possible. When stretched to its maximum, the rubber band will break. However, when we add multiple rubber bands together, we’re able to stretch them farther without breaking. The more PPFs we possess, the better prepared we are to handle life’s challenges.
Through my research with Holocaust survivors and nurses, I’ve categorized the PPFs into four main themes: priorities, purpose, perspective, and personal responsibility (4Ps). Increasing personal resilience isn’t linear; rather, it’s a complex, dynamic developmental process that ebbs and flows depending on our life experiences, environment, personal health, and current emotional state. For this reason, I encourage you to approach this as a lifelong learning adventure. (See Build resilience with the 4Ps.)
Priorities. What matters to you and why? What would you say are your top five priorities in life? Does the way you spend your time and energy accurately reflect these priorities? For many, the answer to the last question is “no.” We frequently sacrifice our true priorities because of other demands on our time, especially those that are work-related. Unfortunately, if left unchecked, this can become routine, leaving us with a life that has little time for what truly matters to us. It’s no wonder many nurses suffer from moral distress and burnout. Our primary sources of joy are missing from our lives. Awareness is the first step in reclaiming our priorities. Identifying them and recognizing the need to put them back into your routine is a big first step to increasing personal resilience.
Our priorities typically are based on our personal values, morals, and professional ethics. They aren’t related to our work/profession but include the people or things that matter most to us, such as our families, friends, and faith. Frequently, we sacrifice these to school or work, leaving us feeling empty, depressed, bitter, or angry. Resilient individuals tend to place great importance on what truly matters to them. We can follow their lead by strategically and intentionally devoting time and energy to our personal priorities. This requires a dedicated focus and commitment to letting go of some of the “noise” or extras that consume our thoughts, energy, and time. You can begin your journey to increased personal resilience by committing to devote time each day to what truly matters to you.
Purpose. Purpose goes hand-in-hand with our priorities, and highly resilient people recognize the meaning (purpose) in their experiences. Your purpose may be something big and overarching in your life that drives most of your behaviors—your “calling.” Not everyone identifies the big purpose, but we can all learn to recognize the meaning that exists in our struggles. Many people refer to this as “finding my why”: Why am I here? What am I supposed to learn from this? How can this experience help others?
Purpose also is helpful when making decisions, especially related to our jobs: Who can benefit from my experiences or what I love to do? How can I use my talents and skills to help someone else? Can I fulfill my purpose here?
Perspective. An informed perspective, especially in times of distress, is critical to resilience. Frequently, we make poor decisions out of an emotional reaction that leads us into further despair. These reactions typically are based on limited information and a narrow perspective. To increase your resilience, strive for an informed perspective that’s broad, diverse, and grounded in evidence. An informed perspective allows you to see the bigger picture, which enhances your decision-making abilities and avoids emotional reactions that may not be based on fact.
Specific steps to improve your perspective include seeking evidence through peer-reviewed resources, making sure you have a diverse network of peer support inside and outside of your organization, and taking time to pause and reflect before choosing a response. Developing an informed perspective requires humility, flexibility, a growth mindset, and self-awareness to recognize the learning and growth opportunities in perceived failures.
Personal responsibility. As nurses, we’re responsible for maintaining our own personal health and sense of well-being. In fact, Provision 5 of the Code of Ethics for Nurses with Interpretive Statements specifically addresses this responsibility: “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.” Recognizing our humanity and imperfection is a sign of maturity and personal growth that strengthens our ability to acknowledge failure and increase our competence through team – work, collaboration, and networking.
Personal responsibility also is about our ability to demonstrate moral courage in advocating for our patients, our colleagues, and ourselves. Moral courage is an antidote to moral distress, but it may require a collective approach—a team effort to face the fears that come with standing up and speaking out.
Putting it all together
Begin building resilience by identifying strategies that you can immediately begin to use in your daily life to strengthen your 4Ps. Complete a personal plan for increased resilience and then find an accountability partner who will commit to joining you. (See Build a resilience plan.) Personal resilience will serve you well when facing the expected challenges of healthcare, including death and dying, rapid change, and compassion fatigue. It also will enhance your overall well-being and ability to face future challenges.
Teresa M. Stephens is an associate professor at the Medical University of South Carolina in Charleston.
American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. 2016. nursingworld.org/coe-view-only
Brigham T, Barden C, Dopp AL, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. National Academy of Medicine. January 29, 2018. nam.edu/journey-construct-encompassing-conceptual-model-factorsaffecting-clinician-well-resilience
Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine. July 5, 2017. nam.edu/burnout-among-health-care-professionals-a-call-to-explore-andaddress-this-underrecognized-threat-to-safe-high-quality-care
McAndrew NS, Leske J, Schroeter K. Moral distress in critical care nursing: The state of the science. Nurs Ethics. 2018;25(5):552-70.
Savel RH, Munro CL. Moral distress, moral courage. Am J Crit Care. 2015;24(4):276-8.
Shanafelt T, Swensen SJ, Woody J, Levin J, Lillie J. Physician and nurse well-being: Seven things hospital boards should know. J Healthc Manag. 2018;63(6):363-9.
Sherman RO. Finding your true north. Nurse Leader. 2017;15(6):370-1.
Stephens TM. Nursing student resilience: A concept clarification. Nurs Forum. 2013;48(2):125-33.
Stephens TM, Smith P, Cherry C. Promoting resilience in new perioperative nurses. AORN J. 2017;105(3):276-84.