Resilience in critical care nurses-is it desirable?

Abstract

This year's British Association of Critical Care Nurses (BACCN) national conference, entitled “Sustainability in Excellence: the Future of Critical Care”, includes a theme on building resilience within critical care nursing. Core to any notion of sustainability is the concept of resilience. But what does this mean for critical care nursing and nurses? There is an abundance of literature promoting resilience as an essential personal characteristic of nurses (Hart et al., 2014; Lanz and Bruk-Lee, 2017; Meyer and Shatto, 2018). There is also an established link made between resilience and staff well-being initiatives (Brenann, 2017). Resilience has become a fashionable ‘buzzword’ implying popularity, trend and positivity. However, is resilience always desirable within critical care nursing? Are we all merely yielding to the dominant positive discourse of resilience, or does it hold beneficial value as a personal attribute of critical care nurses? Resilience, as a term, means to bounce back from difficulties (Turner, 2014). Resilience enables people, including critical care nurses, to recover, cope with stress and manage severe adversities. Being resilient requires agility and flexibility to change in response to surrounding stressors. Resilience is meant to equip us to deal with the physical and emotional pressure of caring for critically ill patients in such a demanding and exhausting environment. We go to work and experience the stress, and there is an expectation that we will naturally physically and mentally bounce back without deliberation activity or attention to the stressor. Resilience in this sense is a ‘springing-back’ process that is meant to leave strong, happy, fulfilled critical care nurses. The converse is burnout, presenting as job dissatisfaction, fatigue, disillusionment and the loss of passion for what it means to be a critical care nurse. Through the lens of resilience as an individual responsibility, burnout could be construed as failing, wastage and potentially depleted caring. Promoting resilience in critical care nurses seems to be common sense and logical. The job is acknowledged to be ‘tough’, but those who choose to work in such a challenging environment are expected to handle the stresses and strains of critical care practice. This ability to accommodate stress includes managing the ever-increasing demand brought about by financial austerity, staff shortages and constant reconfiguration of the critical care services. There is an expectation to do ‘more with less’ and adapt to continual change with an assumption that resilience enables us to bounce back. Is there a breaking point? Much like an elastic band or the Frank-Starling principle about the relationship between end-diastolic volume and stroke volume, there must be a threshold where critical care nurses are over-stretched to the point where personal resilience is insufficient. Critical care colleagues frequently engage in conversations about people's reduced capacity to manage compounding stressors. There seems to be simultaneous ‘change fatigue’ and ‘uncertainty fatigue’ from trying to cope with the daily pressures of working in critical care, alongside an imbalanced health care practice supply and demand. Focusing on strengthening resilience within individuals working in critical care does not necessarily resolve the underpinning cause of these systemic health care pressures. For example, there will always be an expected amount of normal stress that naturally comes with caring for critically ill patients and their families. Whether it is providing end-of-life care, advanced life support resuscitation or monitoring of a stable ventilated patient, critical care nurses need to have some level of resilience to cope with the physical and emotional stress experienced during a clinical shift. Critical care managers, educators and researchers also have stresses that naturally come with each type of role. But the additional strain of contemporary health care's complex financial, environmental and social difficulties appears to be reaching the point where expecting nurses to develop individual resilience is no longer enough for sustainable critical care practice. Traynor (2018) argues the promotion of resilience masks the complexity of wider organizational and national issues and shifts the responsibility of problems away from political and leadership decision-makers onto the individual nurse. According to Traynor (2017), there is unspoken anxiety in the nursing profession from persistent adversity leading to very high student nurse dropout rates, increased turnover of staff and worsening burnout. A recent survey of the critical care nursing workforce in England, Wales and Northern Ireland identified 1440 (8.35%) registered nurse vacancies (Horsfield, 2018). Another survey in the UK by Faculty of Intensive Care Medicine (2018) demonstrated, 62% of critical care units required more nursing staff. That same survey also showed 40% of units had weekly bed closures from low staffing and 80% transferred patients out due to low bed capacity. To promote staff retention in these types of working conditions, Traynor (2017) recommends moving away from traditional views of resilience to a more critical perspective that involves meaningful, sustained and systemic health care changes, rather than just expecting nurses to ‘learn resiliency’ by surviving daily crises in practice with a bare minimum of coping. A combined top-down (strategic health care transformation) and bottom-up (nurse resiliency development) effort could help to rebalance the tipped scale of critical care practice resource supply and demand use. This synergistic, yin-yang approach would then allow top-down and bottom-up perspectives to complement each other because they are not necessarily contradictory. Therefore, a framework for critical care nurse resilience set within an authentic organizational resilient charter for significant transformation of health care practice is urgently required for a truly sustainable service. To address the bottom-up viewpoint, Jackson et al.'s (2018) grounded theory about resilience in critical care nurses, along with other literature about resiliency, could be used by practitioners, managers and educators in critical care while planning and implementing resiliency initiatives (Arrogante and Aparicio-Zaldivar, 2017; Mealer, 2017; Mealer et al., 2017). Critical care nurses may feel that the top-down aspects of resolving the complex health care supply and demand problems fall outside their scope of practice. However, we can all influence leaders and exercise our political power as a collective voice to shape decision-making and activities that help sustain a resilient critical care nursing workforce. The collective voice is key. The BACCN and the annual conference are examples of ways to harness the collaborative will of dedicated, determined critical care nurses and restore our energy to be agents of change. Furthermore, we can only care for other people if we also take care of ourselves and our colleagues within the critical care nursing community. Personal resilience is desirable, but we need to recognize its limitations and simultaneously seek other solutions for sustaining critical care nurses.