Resilience is often derived from personal resources, eg personality traits, cognitive abilities and worldviews, and also from environmental resources eg social support systems, cultural practices and spiritual beliefs (Jackson et al, 2007; Martin-Soelch and Schnyder, 2019). In normal circumstances resilience has been defined as:
Interventions to foster the resilience of healthcare staff include variants of cognitive behavioural therapy, physical exercise, developing social support systems and engagement with the arts either as a recipient or artist, eg through written expression (All-Party Parliamentary Group on Arts, Health and Wellbeing (APPG), 2017; Mealer et al, 2017). However, these activities take time and commitment, neither of which is readily available in and out of the workplace during a pandemic. This is particularly so for nurses who have stepped up to intensive care unit (ICU) care from other departments, often in a baptism of fire.
Reflections on practice
The four components of resilience are not redundant concepts during a pandemic; however, the ways in which they play out may be idiosyncratic and unconventional. Their portrayal can help broaden our understanding of personal resilience and extend its evidence base. This reflection represents one of many possible, valid health worker experiences.
Adjusting to adversity
Resilience can be seen as a dynamic process that enables an ability to move from a vulnerable state, adjust and adapt, thrive and continue to find satisfaction in one's work (Jackson et al, 2007; Grafton et al, 2010). The rapid escalation in COVID-19 cases provided little preparation and processing time. Adjusting to this adverse situation called for an instant ability to share, learn and customise skills.
The shortage of critical care resources, human and material, meant reaching out beyond our designated supplies. New lexicons were forged to help us cope with some aspects of ICU work. Seasoned ICU nurses have needed to share their highly technical expertise with nurses from other specialties and wards. This involved, for example, training and supervising ward level nurses to care for level 3 (intensive care) and level 2 (high dependency) patients. Nurses and doctors from different specialties have learnt from each other, adapting their skills to best suit this new working environment. This has been rewarding, although at times, stressful for all.
Apart from a name and job title scribbled across the front and back, we suddenly became faceless armoured COVID-19 warriors. This has been upsetting, but has also changed how we relate to one another without different colour-coded uniforms or ID to symbolise our status and role. We are simply one team with a shared purpose of giving the best care that we can. Where and when possible we now have teams of ‘donners’ and ‘doffers’ to help us don (put on) and doff (take off) our personal protective equipment (PPE) safely. Teams of nurses and doctors enthusiastically turn up to turn or prone your patient and ‘magic fairies’ scuttle through to tidy your bed space and remove effluent (dialysis waste).
Team spirit has been mostly positive, with every member taking up any role needed that will improve staff and patient safety.
Maintaining equilibrium
Although many types of equilibrium need to be maintained, emotional equilibrium is perhaps one of the most significant coping strategies (Martin-Soelch and Schnyder, 2019). Emotional expression through laughter and tears has become the new normal on some shifts and serves to ground many of our fears, a little like a lightning conductor. Sharing our vulnerabilities has also brought the team closer together. Critical care nurses can be resilient (Mealer et al, 2017), perhaps because our work requires an ability to separate personal emotions from those of our patients to provide them with much-needed support. Further, compassion and empathy for others are central to nursing practice (Upton, 2018). In the pandemic, this has proven challenging due to the frequency and extent of loss of life and dealing with bad news. This is compounded by the fact that the loss is sometimes one of our own nursing or wider healthcare family.
Our own mortality and risk are not often brought to the fore in our work contexts. However, at the beginning, on my way to work I would wonder, ‘Is this, in a way, what it's like for a soldier, policeman or fireman who runs into danger when others are able to run away?’ We break down and cry sometimes, but we also laugh. It is often not long before someone does something nice, such as a local business gifting us some food, water or nourishing creams for our battered faces, or someone does something naughty, like attempting to draw a funny face on your back as they scribble your name. Later on the shift, you may get to ‘meet and see’ the face of the person you have been working with all along for the first time as you both emerge from behind the coronavirus shields. At that moment, the bond formed under the shields blossoms like magic. These are moments that sustain us, that we cherish and embrace.
Retaining a sense of control
Leadership, a critical factor for assuring service responses to the pandemic (The King's Fund, 2020), has been a crucial anchor in the midst of an otherwise chaotic experience. Deciding staff flows in green to red zones, ensuring PPE availability and managing large staff rotas are significant challenges that our leaders have grasped to maintain some control. This includes finding and establishing new ways to communicate with both staff and family members through use of technology. At team level, shared leadership (Forsyth and Mason, 2017) has also been important, particularly with so many different types of nurses and cultures. Potential for clashes is always looming, circumvented by a mutual willingness to learn and be guided to provide the best care possible.
One senses a threat of the physical barriers we have put up between ourselves and the virus through use of PPE and technology becoming barriers to our human needs. This may be so for healthcare workers, patients and relatives. Our communication skills are constantly being tested, and it is an iterative process: learning, reflecting and reconfiguring. Being heard is a constant need, communication is vital, and self-leadership and collaboration are crucial. The organisation and routinisation of as much work as possible gives some semblance of control, eg checklists and turning routines. Nevertheless, it is hard to maintain control of yourself and the job at hand. You start to break your day into chunks and think to yourself, ‘Stay cool until your next break’. It works for the most part until you sense an urgent need to scratch your nose! Then it is simply mind over matter. Trying to maintain control over your patient's vital signs is a particular challenge. We all like to hand over a perfect ‘blood gas’ or brag about how we have weaned this or that drug, but we have had to learn that maybe that is not for today.
Moving on in a positive manner
Every once in a while, a patient or two is extubated from their ventilator and stepped down from the ICU. A few days later you may see that patient talking on the phone, laughing and joking with their friends and family. It is in that moment that we know and remember why we do what we do.
Levels of risk
Nurses, particularly those who work in high-stress environments such as ICU, are thought to be more resilient and at less risk of adverse psychological outcomes (Maunder et al, 2006; Jackson et al. 2007, Mealer et al, 2017). However, there is evidence to warn against possible complacency, for example, studies into the severe acute respiratory syndrome (SARS) and Ebola epidemics identified a high level of post-traumatic consequences for healthcare workers (Tam et al, 2004; Wu et al, 2009; Paladino et al, 2017). Risk factors such as high workloads and lack of protective equipment are a great source of fear and stress (Mealer et al, 2017; Joob and Wiwanitkit, 2020). The loss of a colleague, family member or friend, as well as the risk to one's own mortality, are emergent concerns associated with this pandemic for which we were ill prepared.
These risks are not simply experienced by ICU and emergency staff (Wu et al, 2009), but affect all NHS staff ranging from clinicians in other departments to managers, administrators, porters, cleaners and cooks. The resilience of key support staff in hospital settings has rarely been addressed in the literature, although it is known from the SARS epidemic that healthcare staff from all departments were affected (Chan and Huak, 2004). More recent findings from China have indicated that staff experienced clinically significant depressive symptoms regardless of whether or not they were exposed to patients with COVID-19 (Liang et al, 2020). For this reason, it is perhaps crucial to understand each individual's vulnerability and resilience attributes, for example age, sex and previous exposure (Martin-Soelch and Schnyder, 2019).
Although not exhaustive, Box 1 summarises key risk factors that mediate stress and recovery from pandemic-related psychological trauma. These are drawn from the author's experience during recent ICU practice and also from the literature, which confirms their influence on the psychological impact of stressful events (Martin-Soelch and Schnyder, 2019; Hou et al, 2020; Wald, 2020). Each is worthy of careful appraisal to promote the resilience of healthcare staff as well as their leaders.
| Prerequisites |
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| Perception of risk |
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| Work related |
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| Physical comfort |
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| Social |
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Minimising and managing risk
Pandemic resilience has become an ongoing need in today's health systems (World Health Organization (WHO), 2019). Preparations, for example through effective risk communication and the availability of psychological first aid, are likely to minimise the psychological impact of experiencing prolonged acute stress (Maunder et al, 2006; Lehmann et al, 2016). As an example, during the Ebola crisis, a proactive monitoring system was used in Africa to understand acute and cumulative risk using evidence-based risk metrics as they occurred (Schreiber et al, 2019). The model has three components (A, P and D):
Use of the APD model or similar measures may protect staff from the negative psychological consequences of cumulative stressors. However, further research is needed to evaluate its effectiveness compared with ‘deployment as usual’ (Schreiber et al, 2019).
Support at individual and organisational level through effective leadership, provision of material resources, and effective training and support is crucial (Intensive Care Society (ICS), 2020; The King's Fund, 2020; Royal College of Nursing (RCN), 2020). The literature provides suggestions on how to cope with stress, for example, structured work environments and shorter shifts (Su et al, 2007; Lehmann et al, 2016); Fessell and Cherniss (2020) encourage practising emotional awareness and mindfulness while performing hand hygiene. The ICS, The King's Fund and the RCN have recently provided guidance, signposting and downloadable resources to support mental wellbeing and resilience during the COVID-19 pandemic (Box 2). These comprise personal strategies (ICS and RCN), as well as organisational strategies (The King's Fund).
Implications for research
For most of us living today, COVID-19 is the only pandemic we have experienced. Research into such phenomena is therefore limited and that which does exist is retrospective. However, given recent history and the increasing integration of continents through trade and travel, we might reasonably expect epidemics and possible pandemics to occur with increasing frequency (WHO, 2019). Increasing our understanding of resilience in crisis situations, as well as how to better prepare, is of paramount importance to assure a safe and able workforce (Jackson et al, 2018). Phenomenological and narrative studies that draw on the lived experience of healthcare staff involved in the care of patients with COVID-19 will be invaluable. They can inform the development of pandemic preparedness policies and provide frontline workers and their leaders with first-hand knowledge of stress points and coping strategies.
Cultural influences on resilience have implications for an NHS workforce in which approximately 45% of medical staff are non-white (NHS Digital, 2020), and 20% of nurses, midwives and health visitors are non-white; the proportion is significantly higher in some regions and inner city areas (NHS Improvement and NHS England, 2019). We need to understand how our multinational and multicultural NHS workforce fared during the current pandemic and identify the risks to resilience or ameliorative actions that are culturally based. It is also of interest to know how established and recently recruited ICU nurses experienced the pandemic and the effects it had on their resilience.
Conclusion
Psychological risk cannot be completely avoided during pandemics due to their emergent nature, and initial challenges faced when implementing strategies can never be completely eliminated. However, there is abundant evidence of staff resilience across NHS services and this article has highlighted some of its features. Ward-level and other nurses have risen to the challenge of specialised roles; ICU nurses and medical colleagues have learnt to share their specialty with others who have willingly transferred and reshaped their skill sets, problem-solving at speed in moments of acute pressure, channelling emotions in partnership with colleagues, sharing vulnerabilities and infusing scientific practice with the arts and humanities.
The team spirit that resides in all COVID-19 wards and hospitals has provided much needed interpersonal and social support. Added to this, wider community support has given many staff an extra morale boost. These are unprecedented times in most of our careers, and we are acutely aware that the emotional burden of our experiences may not be immediately apparent. Personal, interpersonal and community coping skills are vital and may determine the long-term resilience of us all.