Facing change: developing resilience for staff, associate specialist, and specialty doctorsBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g251 (Published 22 January 2014) Cite this as: BMJ 2014;348:g251
- Catherine Tregoning, postdoctoral research fellow,
- Shirley Remington, associate dean,
- Steven Agius, senior research fellow
There is growing recognition of the importance of resilience for doctors and their careers. Catherine Tregoning, Shirley Remington, and Steven Agius describe an initiative to introduce resilience workshops for SAS doctors
Resilience has been defined as the “ability to bounce back or recover from stress.”1 It is also often referred to as hardiness or buoyancy or the possession of coping mechanisms. It entails the adoption of positive coping strategies, in times of change or adversity, to enable people to carry on in their jobs and lives.
The ongoing changes inherent in working in a rapidly changing workplace, together with personal demands such as caring for children, coping with illness, and moving to a new part of the country, require medical trainees to develop “career resilience” or “self reliance” to cope.
Resilience among medical professionals has been the subject of academic inquiry around the world, generating a limited, but growing, body of literature (box 1). In the United States, there is recognition of the increased likelihood of burnout in physicians who lack resilience and among those with multiple roles, such as clinical academics.2 In response to this increased awareness, teaching hospitals and medical schools such as Rochester’s School of Medicine and Dentistry are beginning to teach resilience.2
At the North Western Deanery, now part of Health Education North West, lead educators proposed that a workshop to develop resilience could be of potential benefit to doctors. Initial sessions were delivered to groups of staff and associate specialist (SAS) doctors (box 2). This was the first time that resilience workshops had been run by the North Western Deanery. SAS doctors were targeted because there is evidence that they can feel undervalued and find career progression difficult. They may also perceive themselves as being at greater employment risk in times of financial pressure within the NHS.3
In total, 40 doctors attended the workshops and 38 completed an evaluation sheet at the end of the day, resulting in a 95.0% response rate. As part of the follow-up evaluation, responses were obtained from 23 attendees across all three original workshops, resulting in a 60.5% response rate. However, response rates varied across trusts and around half the respondents were from one trust. Only three responses were obtained from one of the workshop groups, which may have limited the knowledge gained through the evaluation.
At the end of the workshop, participants were asked to share any objectives they had for the resilience session. Their responses included: “Improve awareness of self and ways of increasing resilience,” “Learn the skill to cope with change and conflict,” “Improve [my] career,” and “Ways to deal with changes and become more resilient to change in the modern NHS.” The evaluation sheets that the participants completed suggested the sessions were successful in achieving these aims. On average, participants rated how well their objectives had been achieved as 4.4, on a scale where 1 was the most negative and 5 the most positive.
The sessions also seem to have increased participants’ understanding of resilience. On average, participants rated their understanding of resilience as 3.0 before the workshop and 4.7 after it. When asked to list the three aspects of the workshop they had found most useful, participants listed particular practical aspects of the sessions, as well as personal insight they had gained during the sessions. Practical aspects included the online resilience questionnaire and the skills identification exercise. Personal aspects included gaining greater self awareness, insight, and clarity, as well as reflecting on resilience characteristics of others. Respondents said they would have benefitted from spending more time doing in-depth activities.
Participants generally envisaged that the workshop would have a positive impact on their working life. In their responses, participants said they thought it would, “Create better work-life balance,” enable them to “Try to be more flexible and achieve as much as possible from current surroundings,” “Change my perspective to work life and my attitude and behaviour,” “Help me set new goals for my career and work,” and “Help me make the best use of my present circumstances and capabilities for the future.”
Respondents were questioned two to three months after the workshops about the extent to which they had used what they had learnt about resilience in the session. They all said they had used it to some extent, with 15 saying they had used it either “a reasonable amount” or “a lot.” In 10 cases, respondents had applied their new knowledge, “Mostly in my working life but also to an extent in my personal life too.” In six cases, they had used it, “Equally in both my work and personal lives.” Other respondents reported having used resilience skills in either their personal or working lives exclusively, or in their personal lives more than their working lives.
The evaluation asked respondents to share what parts of the session were most useful. Representative answers included: “It was the awareness that I have inborn resilience, which has boosted my confidence/ performance etc,” “Changes are inevitably part of life and one has to adapt to it in order to continue to work in the competitive world,” “Skills analysis helped me to identify my skills indepth and to identify my strengths and areas of development,” “Making feasible targets and trying to achieve them,” and “All of it.”
Our findings suggest that SAS doctors generally may find resilience training to be beneficial and that workshops on the subject can usefully increase their understanding of resilience. Resilience training was beneficial to both the working and personal lives of most of the doctors in our sample. Respondents’ evaluation of the session informed the decision of the SAS doctors’ implementation group of Health Education North West to provide further workshops for these doctors.
Although attendance at the workshops was limited to SAS doctors employed in the north west of England, it is likely that the results apply to doctors working elsewhere. Many of the challenges that doctors face, such as witnessing human suffering, may be experienced by doctors working in a wide range of settings, regardless of their geographical location.4 All doctors will, at some stage, face demands of studying for exams alongside working, and the problem of coping with shift work.5
Research has looked at doctors working in challenging conditions and analysed why some doctors can, despite the demands they face, thrive rather than burn out. This research suggests that mentors can highlight the positives of working within specific areas of practice and use this to develop resilience in their mentees.6 These findings show that even those doctors who work in the most difficult conditions can develop resilience and job satisfaction with the right support.
It could be suggested that all doctors must possess a degree of resilience, since they are able to cope with working in the profession. This was recognised by attendees of the workshops, such as the participant who wrote, “It was the awareness that I have inborn resilience which has boosted my confidence/performance.”
Although our study sample was small, with 38 participants at stage one and 23 at stage two, good response rates were achieved at both stages. It could be argued that, since SAS doctors self selected themselves on to the workshops, they may have been individuals who were more open to the concept of developing resilience, and thus more likely to view the workshop positively.
Resilience workshops may be of benefit to other SAS doctors and other medical practitioner groups, as this evaluation has shown them to have a positive impact on doctors’ lives. Additional work may be needed to tailor workshops to other specific groups, such as doctors in training, who may have particular requirements. Further research would be useful to clarify how such a targeted intervention might need to be delivered differently.
Participants’ suggestions indicate that workshops may also need to be longer to include more time to do further in-depth activities. From the wider literature, the suggestion of providing mentors to develop resilience may also be worthy of consideration.
The term derives from the Latin word “resiliens,” which refers to the elastic quality of a substance—its ability to be stretched and then return to its normal state of functioning. Increased resilience is an advantage in a rapidly changing work environment such as the NHS.5 Resilience is a widely researched topic and resilience training is high on the agenda of many organisations, from Barnardo’s providing workshops for children leaving care,7 to the US army using resilience training to prevent post-traumatic stress disorder.8
After a literature review, a team of four experienced trainers, including a senior clinician and a chartered psychologist, identified topics relevant to developing resilience among medical staff for inclusion in the workshop. Topics included change, motivation, stress, locus of control, skills identification, and positive psychology. Activities were developed to produce a full day of sessions covering the identified topics. This incorporated the Resilience Quotient questionnaire, a free online tool developed by Nicholson McBride, an established company of business psychologists.9 Other tools were trialled, but they were considered to be less appropriate for medical staff. The team also used a skills self assessment tool from the Windmills career management suite.10
Data were collected across two stages. During stage one, three separate one day workshops were delivered at sites across the north west of England. SAS doctors were invited to attend via emails distributed through trust SAS leads. Assessment was by evaluation sheet, with sheets being completed anonymously and collected at the end of each session. This method of data collection was chosen as it was thought that a large number of responses could be gained in a short period of time before attendees left the workshop. The sheet had nine short questions, including both open and closed ended questions and Likert-type scales. The questions examined attendees’ objectives in attending the workshop and considered how well these had been achieved. They also asked about attendees’ understanding of resilience before and after the workshop, about what attendees had found useful, and how they thought the workshop might impact on their working lives.
Stage two of the data collection took place between two and three months later. Each of the stage one participants was emailed and invited to complete a follow-up evaluation via an online survey tool, and two email reminders were sent at weekly intervals. An online survey tool was chosen because it required little time commitment from participants and so would help to maximise the number of responses gathered. The second stage evaluation sought to investigate any potential long term benefits gained from attending the workshop. Six questions were included, examining whether and how participants had used what they had learnt about resilience in the session and what aspects of the session had been most useful.
We thank Carole Kennedy, Royal Bolton Hospital, and Gill Phazey, Health Education North West, for their contribution in helping to deliver workshops.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.