Issues in Mental Health Nursing, 35:33–40, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.836261
Mental Health Nursing in Australia: Resilience as a Means of Sustaining the Specialty Michelle Cleary, RN, PhD∗ National University of Singapore, Yong Loo Lin School of Medicine, Singapore
Debra Jackson, RN, PhD Issues Ment Health Nurs Downloaded from informahealthcare.com by Nyu Medical Center on 04/19/15 For personal use only.
University of Technology, Faculty of Health, Sydney, NSW, Australia
Catherine L. Hungerford, RN, PhD∗ University of Canberra, Disciplines of Nursing and Midwifery, Faculty of Health, Canberra, Australia
dividual characteristic that supports an individual to withstand, adapt to, and develop in the face of change (Grafton, Gillespie, & Henderson, 2010; Koen, van Eeden, & Wissing, 2011). Others suggest resilience can be learned or developed, with resilient behaviours and practices an important means of assisting individuals to transcend and transform negative experiences into positive self-enhancing learning (Hodges, Keeley, & Troyan, 2008; Nucifora, Langlieb, Siegal, Everly, & Kaminsky, 2007; Warelow & Edward, 2007). Resilience also has been categorised according to context. There is personal resilience (Gallos, 2008; Grafton et al., 2010; Koen et al., 2011), workplace resilience (Cleary, Horsfall, & Jackson, 2013; Deacon & Cleary, 2013; Jackson, Firtko, & Edenborough, 2007), organisational resilience (Altman Dautoff, 2002; Gibson, 2010; Seville et al., 2008), community resilience (Bajayo, 2012; Pfefferbaum et al., 2013), and professional resilience (Ashby, Ryan, Gray, & James, 2013; Hodges et al., 2008). Resilience also has been positioned as a quality that can be nurtured by individuals and used to mitigate workplace adversity (Jackson et al., 2007). Few studies, however, have defined or considered the notion of group or collective resilience of a profession, including the capacity of that profession to withstand adversity and continue to develop positively in the face of change. This article considers the notion of resilience from the perspective of the specialty of mental health nursing in the Australian context, including the ways the specialty has adapted—and continues to develop—to changes since deinstitutionalisation. Insights are drawn from a national Delphi study undertaken in Australia to develop a Scope of Practice for Mental Health Nurses, with responses used as a springboard to consider the impact of the perceived loss of professional identity on the collective resilience of the profession. Although this article focuses on the Australian situation, we believe that the
As a concept, resilience is continuing to attract considerable attention and its importance across various life domains is increasingly recognised. Few studies, however, have defined or considered the notion of the group or collective resilience of a profession, including the capacity of that profession to withstand adversity and continue to develop positively in the face of change. This article considers the notion of resilience from the perspective of the specialty of mental health nursing, including the ways the specialty has adapted— and continues to develop—to changes experienced since deinstitutionalisation. Insights are drawn from a national Delphi study undertaken in Australia to develop a Scope of Practice for Mental Health Nurses, with responses used as a springboard to consider the impact of the perceived loss of professional identity on the collective resilience of the profession. Recommendations for a way forward for the profession are considered, including the ways in which a collective professional resilience could be developed to sustain and strengthen the professional identity of mental health nursing in Australia and across the globe.
As a concept, resilience is continuing to attract considerable attention and its importance across various life domains is increasingly recognised. Definitions of resilience are wideranging and the concept is conceptualised in various ways. Some view resilience as a power within—an innate and inThe authors acknowledge the assistance of Donna Hodgson (ACT Health) and Peta Marks (Australian College of Mental Health Nurses), the support of Kim Ryan (Australian College of Mental Health Nurses) and Rhonda Wilson (University of New England) in relation to the Scope of Practice Project, and Dr. Jan Horsfall for her review of an earlier draft of the paper. ∗ These two authors contributed equally to this article. Address correspondence to Michelle Cleary, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597. E-mail: [email protected] or michelle [email protected]
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recommendations arising from the study provide a potential way forward for the specialty internationally, and argue that collective professional resilience can be developed to sustain and strengthen the professional identity of mental health nursing across the globe.
A CHANGING PROFESSION The advent of deinstitutionalization in Western nations brought about a number of significant changes not only for health professionals, but also for people living with a mental illness, their care givers and other family members, and the community. For example, there has been a transformation of the psychiatric nurse into the mental health nurse, with a greater focus on health and wellness rather than illness and pathology (Chapman, 1997). Although this change in positioning has provided many more opportunities for mental health nurses, including expanded and extended roles in the community and primary health contexts, it also has led to a departure from or, perhaps, less recognition of the more traditional and perhaps definitive roles (Walsh, Cleary, & Dowling, 2012). Achieving such a significant transformation has required considerable flexibility and adaptability for the mental health nursing specialty as a whole. In Australia, major changes in national policy gave rise to the dual process of de-institutionalisation and the mainstreaming of mental health services into the general health care system from the 1970s. For mental health nurses, these changes generated a number of issues. Of particular concern has been the issue of the recruitment and retention of nurses to work in the field of mental health, together with high levels of stress and burnout (Cleary & Happell, 2005; Cleary, Horsfall, & Happell, 2009; Cleary, Matheson, & Happell, 2009; Jackson & O’Brien, 2013). Happell (2009) linked these issues to a diminution in the standing and appeal of mental health as a field of practice for nurses, and positioned this as a consequence of changes in the way in which mental health nurses are currently educated and regulated (similarly, Stevens, Browne, & Graham, 2013). These changes meant that mental health nursing ceased to have a unique registration (e.g., psychiatric, mental retardation). Currently, all registered nurses in Australia, irrespective of specialty area, are required to complete a generic Bachelor of Nursing degree, which means that all newly graduated registered nurses are considered to be eligible to enter the specialist mental health nursing environment. Indeed, national legislation does not require registered nurses to hold a specialist qualification to work in the field of mental health. This loss of a separate registration for mental health nurses has created uncertainty for many people, including other nurses and health professionals, as to the precise nature of the work of the mental health nurse; how this work is different to other nurses; and whether the mental health nursing is, indeed, a specialty in its own right (Holmes, 2001; Crowther & Ragusa, 2011). It should be noted however, that there are still nurses working in mental health
settings who were prepared within the hospital-based system and awarded the qualification of Registered Psychiatric Nurse (RPN). This qualification is recognised for registration, but the education pathway specific to mental health via hospital training has not been an option since the early 1980s. Instead, specialist mental health qualifications (graduate diploma, masters or doctorate) must now be obtained by registered nurses by undertaking tertiary-level study. This system has many differences compared to other countries. For example, in the United States, nursing is considered to be both a profession and a discipline, with psychiatric-mental health nursing being a nursing specialty.
DEFINING THE PROFESSION In response to the widespread uncertainty generated by deinstitutionalization and changes in the education and registration of mental health nurses, the peak professional body for mental health nurses in Australia, the Australian College of Mental Health Nurses, supported the conduct of an ethics committeeapproved National Scope of Practice Project in 2012–2013, with a view to more precisely describe the work of the contemporary mental health nurse. The Delphi Method is a structured approach to research that has been used extensively in the field of health to develop policy, scopes of practice, and practice frameworks (Keeney, Hasson, & McKenna, 2011; McIlrath, Keeney, McKenna, & McLaughlin, 2010; McKenna, Keeney, & Bradley, 2003). It comprises a number of stages, with each building on the previous stage, and utilizes a purposive sample of experts who collaboratively examine a particular topic, issue, or question and together mediate agreement on the meaning of this topic, issue, or question to generate new knowledge (McKenna, Keeney, & Bradley, 2003). The national Scope of Practice Project utilised four rounds, with the first round comprising a purposeful sample of registered nurses who had worked in the field of mental health for at least three years. A total of 1,162 registered nurses from across Australia participated in this round of the project. Each of these nurses was asked to provide feedback on a draft document that had been developed from a range of sources, including published research findings and policy documents; the draft document described the scope of practice of mental health nurses, as individuals and also collectively. The first round of the survey asked participants to respond to 14 statements related to scope of practice. The first question related to each statement used a Likert-type scale, with 1 being the rating for statements that participants’ considered of little importance and 10 being the rating for statements with substantial importance. The second question related to each statement asked participants to provide more feedback about the statement, if they wished, using an open-text response. Completion rates of the questions related to the first question ranged from 832 (68.5%) to 1,004 (82.7%), with these responses averaging 878 (72%). Response rates to the open-ended questions, the
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second question attached to each statement, ranged from 61 (5%) to 236 (20%), with the average number being 138 (11.8%).
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Who Are We? Although the majority of participants concentrated on providing feedback on the specific questions asked about the scope of practice of mental health nurses, a small number of participants used the opportunity as a platform to express how past, and more recent, structural changes in the mental health nursing profession have affected individuals. Many of these comments relate to notions of identity and a need to belong or feel accepted—and also showed some division within the profession: For me, being listed as an RN [Registered Nurse] instead of an RPN [Registered Psychiatric Nurse] has had a huge impact on my identity, as it has on a lot of nurses . . . We are no longer acknowledged for the profession we trained in!
Participants also identified outcomes of this loss of identity and lack of acknowledgement: The fact that all RNs can now work in mental health without mental health education or training has lost RPNs from the profession!
This loss of identity had caused some respondents to consider leaving the profession. In addition to leaving the profession, some nurses also described an awareness of their loss of commitment to supporting newly graduated nurses: The lack of respect from RNs towards us RPNs is why many of us will no longer supervise new grads, which is always vital in practice.
Others, again, noted an increase in the blurring of roles, the result of a new emphasis on the multidisciplinary team, and the impact of this on the mental health nursing specialty: The profession of mental health nurses needs to be recognized as its own specialty, instead of getting lost or confused within the allied professional scope. More and more community mental health roles are no longer specific but generic positions, as if allied health [professionals] have the same training and speciality as mental health nurses! This takes away from the mental health nursing profession!
Perhaps most significant was feedback expressing the alternative position, which suggests that many respondents felt they don’t belong or have not been welcomed into the mental health nursing fold: They sneer at me because I’m comprehensively educated. Apparently, if you haven’t done your time in “the bins,” you’re second rate! I’m sick and tired of the number of conferences I’ve attended where “Mary Smith” is lauded because she has worked in mental health for 30+ years. Apparently longevity is the only real badge of honour. Having a degree doesn’t seem to count. They stare down their noses at us and all I can think is . . . “Get over it and get with the times!” I’ve stopped going to the mental health nursing conferences—why line up to be marginalised by your so-called colleagues?
Clearly, a situation in which nurses practicing in the field do not feel fully accepted by colleagues has the potential to substan-
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tially weaken the profession. The need to address these identity issues was quite succinctly captured by one respondent: There needs to be an absolute identity re-established to recognize the mental health nursing profession!
Without this recognition, with this “absolute identity” that would enable mental health nurses to connect to one another, to be part of the group, to belong, one participant foresaw the gradual demise of the profession. This raises the question of how the mental health nursing profession as a whole will withstand, adapt to, and develop in the face of the quite significant changes experienced over the past few decades. Whilst a definitive scope of practice for mental health nurses suggests one way forward, it is not the only answer. This is because the scope of practice of mental health nurses encompasses a wide range of nursing and health care roles and functions; with diversity needed to promote optimal physical and mental health, prevent physical and mental illness, and support the physical and mental health preferences and needs of individuals, communities, and population groups. Moreover, the scope of practice of mental health nurses, like all nurses, will change and develop over time, in response to a range of contextual factors. Findings from this round of the study raised some very interesting questions about resilience in relation to mental health nursing. In the face of considerable and ongoing change, how resilient is the mental health nursing profession? Or, perhaps more importantly, how can the profession develop the levels of resilience required to meet the challenges at hand? RESILIENCE AND MENTAL HEALTH NURSES There is scant discussion in the literature related to the resilience of a profession. Over 20 years ago, Isaacson and Ford (1998) discussed notions of professional resilience in the context of organisational theory and recommended a redefinition of leadership where activities are distributed across the members of a group (rather than confined by hierarchical positioning or personal characteristics) to support the health and wellness of that group. Integrated into this horizontal model of leadership was the concept of ongoing learning at the individual and group levels, to increase the capacity of everyone to address problems as they arise. More recently, Ashby et al. (2013) identify a dynamic relationship among professional identity, professional practice, and professional resilience, and argue that professional resilience is sustained by strategies to maintain professional identity. These strategies include health professionals participating in clinical supervision, establishing support networks, and finding employment that allows a match between valued knowledge and opportunities to use that knowledge in practice. This notion of professional resilience, however, seems more aligned with the individual as a professional person, rather than the collective resilience of a profession as a whole. In light of the notion that an
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organisation or group is more than the sum of the parts, or members of the organisation or group, the notion of the collective resilience of the group requires a more focussed consideration. Personal Resilience The concept of personal resilience overlaps with the associated notions of having self-efficacy; tolerating ambiguity; having self-awareness; making meaning out of disorder; demonstrating realistic perseverance; and having the ability to analyse and appraise a situation, the tendency to interpret change or obstacles as manageable challenges, and the capacity to access relevant support (Grafton et al., 2010; Koen et al., 2011). Adequately resilient people are generally able to flexibly draw on a range of inner and outer resources and problemsolving strategies to manage and recover from stress or adversity (Antonovsky, 1987; Burton, Pakenham, & Brown, 2010; Kinman & Grant, 2011; Klohnen, 1996). Personal resilience also has been described as a continuum of adaptability that includes a range of capacities that allows people to manage change and diverse demands in their private and professional lives (Jackson et al., 2007). Moreover, personal resilience is not a fixed inherited dispositional characteristic and is, therefore, potentially amenable to strengthening by supporting individuals to “[recognise] choices for how to interpret and respond to events, keeping things in perspective, trusting one’s instincts, practicing new behaviours, and reflecting on the consequences” (Gallos, 2008, p. 363). Some have argued that resilience overlaps with the notion of emotional intelligence (Keshavarzi & Yousefi, 2012). The five domains of emotional intelligence outlined by Goleman (1996) are: emotional self-awareness; managing one’s own feelings so that they are not impeding; self-motivation in the service of goals; empathy—recognizing and respecting other people’s feelings; and social competence, which includes assertive communication and interpersonal responsiveness. People with welldeveloped emotional intelligence—that is, those who are empathetic and self-reflective—are likely to be more resilient under duress (Kinman & Grant, 2011) and “bounce back from adversity, persevere through difficult times, and return to a state of internal equilibrium or a state of healthy being” (Edward, 2005, p. 142). Typically, these resilient individuals will have clear boundaries, structured work routines, effective communication skills, good peer support networks, and they will be self-aware in that they are able to realistically recognize their strengths and limitations (Jensen, Trollope-Kumar, Waters, & Everson, 2008; Kinman & Grant, 2011). Professional Resilience Resilience also is dependent upon the fit between the individual and the context in which the individual is located. This includes the professional context. For example, the personal resilience of nurses is viewed as a valuable asset, because it can augment adaptability and practical and emotional well-being in
professional contexts that are often demanding and occasionally volatile (McDonald, Jackson, Wilkes, & Vickers, 2012). At the same time, however, professional resilience for nurses is by no means a “one size fits all” construct. For example, an individual mental health nurse may be resilient under stressors associated with high-adrenaline demands in a crisis or emergency setting, but be less resilient when working in a unit where most consumers are depressed and externally produced action is missing. This suggests connections between resilience and workplace satisfaction or enjoyment. Indeed, workplace satisfaction and enjoyment may well be a protective factor in the context of workplace adversity—as noted by Manion (2003), “[the way] we feel about and enjoy our work is crucial to how we perceive the quality of our lives . . . [but this] loss of joy is more than a personal issue; it is also an organizational issue” (Manion, 2003, p. 652). Promoting workplace enjoyment and satisfaction, however, is something of an art in today’s highly competitive and stressful workplace (Davidhizar & Hart, 2006). Hence, professional resilience is both an individual and organisational trait—and responsibility. Indeed, under present day circumstances, it is more strategic and effective for organisations to support and maintain employee resilience, than to re-develop resilience within the working group once it has waned. With resilience dependent upon the extent of the protection that is available to a person visa` -vis the level of adversity they are experiencing (Antonovsky, 1987), there is good reason to consider the role of employers and organisations in supporting professional resilience.
Group Resilience Definitions of group resilience are rare in the literature. Henman (1998) identified how interdependency, competition, structure, and supporting others to avoid apathy supported resilience in groups of prisoners of war in Vietnam. Altman Dautoff (2002) identifies the group attributes of flexibility, confidence to solve problems, and a common purpose, before going on to suggest that group resilience can be improved by building individual resilience skills, ensuring adequate resources are available for the group to achieve their goals, and providing acknowledgment and reward for group achievements. In contrast, definitions of community resilience in the literature abound. This category of resilience has been linked to notions of sustainability through people collaborating, sharing resources, and supporting one another to develop skills as they work towards a common goal (Bajayo, 2012; Castleden, McKee, Murray, & Leonardi, 2011; Pfefferbaum et al., 2013). Sousa, Haj-Yahia, Feldman, and Lee (2013) connect community resilience with optimism, hope, determination, and also a common values base. As a group, even community, the profession of mental health nursing can be described as a resilient group by virtue of its survival and continued development through the many, very substantial, internal and external changes experienced over the last few decades. A definition of this collective resilience can be
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drawn from the definitions of personal, professional, and group resilience provided above. This is because the mental health nursing profession is a composite of people with varying levels of personal and professional resilience. At the same time, the mental health nursing profession is much more than this; as a group, it is greater than the sum of its parts. To enable its own long term sustainability, then, the resilience of the profession will rest upon its own self-awareness, cooperation, acknowledgment of achievement and, perhaps most importantly, critical reflection. This must be combined with notions of hope, optimism, and determination to building a better profession for future generations. However, whilst such attributes provide a common goal to work toward, the more pragmatic questions also must be addressed. With the mental health nursing profession in Australia, and further afield, encompassing such a wide range of nursing and health care roles and functions, how can the collective resilience of this group be nurtured and developed?
TOWARDS BUILDING THE COLLECTIVE RESILIENCE OF THE MENTAL HEALTH NURSING SPECIALTY Koen et al. (2011) argue that resilience levels in groups of nurses and, by association, the profession as a whole, can be improved through the implementation of organisational and personal stress-management strategies. Promoting, supporting, and developing the collective resilience of the mental health nursing specialty, then, is the responsibility of the individual, employers, and professional bodies. By taking the initiative and exercising a horizontal leadership style to be proactive—all characteristics of resilient health professionals (Nucifora et al., 2007)—much can be done to foster professional resilience. Activities for Individuals A range of activities with the capacity to be adapted to meet the needs of the mental health nursing profession are recommended in the literature. For example, peer support is an important aspect of a cohesive group, demonstrating a willingness to provide support and guidance and also a valuing of others in the profession (Gillespie, Chaboyer, Wallis, & Grimbeek, 2007). Establishment of peer support networks, as well as opportunities for mentoring and skills-sharing, is something individual mental health nurses, employers, and also professional bodies can facilitate (Cleary, Horsfall, O’Hara-Aarons, Jackson, & Hunt, 2011; Cleary, Walter, Horsfall, & Matheson, 2009). Ideally, such networks would enable a sharing of responsibilities—together with the building and developing of personal, professional, and group bonds, both within and outside of the nurses’ immediate working environments. This would allow nurses to build supportive networks that support professional resilience locally and, by association, further afield (East, Jackson, O’Brien, & Peters, 2010; Jackson et al., 2007). Of particular note is the capacity of those involved to build and focus on the strengths, rather than the challenges, of the individuals and group; that is, identifying
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what is working for the mental health nursing profession rather than what is not (Darbyshire & Jackson, 2004-2005). Optimism has been identified as an important aspect of resilience for individuals (Deveson, 2003; Jackson et al., 2007) and is associated with building capacity in groups (Jackson, 2008). Research also shows that together with a cohesive culture that promotes participation, good staff morale, and a sense of commitment (Davies, Mannion, Jacobs, Powell, & Marshall, 2007), an inclusive group or team work approach (e.g., individuals sharing work, good communication, practical support) is essential for creating and maintaining optimistic and, by association, resilient professional groups (Cleary, Horsfall, O’Hara-Aarons, & Hunt, 2012; Deacon & Cleary, 2013). Teams get the work done in busy, sometimes chaotic mental health settings; teams also allow for camaraderie, sharing achievements, and fun. For this reason, wherever possible, it is important that individual mental health nurses work together in professional teams, supporting one another and, in so doing, developing a group identity. Effective leadership is crucial in fostering the growth of strong and resilient work teams, and in creating environments for community values to develop in work teams (Jackson, 2008). Strong and nurturing teams also will contribute to the development of future leaders within the profession, as well as supporting the role modelling of desirable mental health nursing behaviours (Cleary et al., 2013). Other ways the individual can promote team or group resilience are to welcome diversity, and treat each other in courteous and respectful ways, whilst appreciating difference and the capacity for each individual to make a unique contribution (Ely & Roberts, 2008). The “one size fits all” approach and the “but we’ve always done it this way” reflex have no place in a profession that is marked by a diverse and wide range of nursing and health care roles and functions (Cleary, Horsfall, Mannix, O’Hara-Aarons, & Jackson, 2011; Deacon & Cleary, 2013; Hungerford & Hodgson, 2013). Moreover, it is important that leaders of the profession challenge such attitudes. As noted by Dolan, Strodl, and Hamernik (2012), team building strategies can be used to promote an appreciation of differences in relation to education, experience, cultural background, and everyday work challenges as well as decrease prejudice and workplace discrimination or intra/professional marginalisation.
Activities for Managers It is important that managers—senior, middle and frontline—rise to the challenge of supporting the development of a resilient profession. As already noted, recruitment and retention of mental health nurses continue to be significant challenges for health services worldwide. Taking steps to build resilience into the profession, then, will value-add in the long term. Such steps may include the provision of providing positive, profession-enhancing experiences for employees (Warelow & Edward, 2007) together with ensuring appropriate support, including in-service education for mental health nurses, to better
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help them appropriately manage the many challenges they face in their working lives (Edward, Welch, & Chater, 2009). Further, managers need to apprise themselves of the quality of the workplace atmosphere for mental health nurses and also inter-professionally (Khadjehturian, 2012). Questions to be asked of the workplace may include: Is the unique role and work of the mental health nurse understood, valued, and respected in this environment? Are the concerns of mental health nurses being listened to, acknowledged, and responded to in timely and appropriate ways to support and maintain a healthy and enabling work milieu (Davidhizar & Hart, 2006)? Research findings show that when nursing work is acknowledged and appreciated, positive outcomes are more readily achieved (Cleary et al., 2012). This is not surprising, given that most people want to make a difference, engage in meaningful work activities, and make constructive contributions to achieve positive ends. At the same time, research findings also suggest the need for managers to be concerned with organisational justice, adequate workplace supports, and the use of communication styles, by all, that are respectful, clear, and encourage staff participation (Jane-Llopis et al., 2011).
Activities for Organisations From an organisational point of view, it is important to support the empowerment of the profession of mental health nursing, with empowerment closely related to resilience (Pines et al., 2012). For example, staff with some control over their job, flexible working arrangements, and a viable workload are more productive, and respond well to positive feedback and praise rather than externally imposed rules and fault-finding (JaneLlopis et al., 2011). Likewise, when mental health settings support leadership practices that are aligned with consumer-centred recovery, these setting will include mutual respect, effective communication, ethical practice, and a valuing of collaboration to create job satisfaction and improve morale, above and beyond good patient outcomes (Cleary, Horsfall, Deacon, & Jackson, 2011). For the mental health nursing profession, this suggests the value of individual mental health nurses taking the lead and demonstrating understanding of the issues involved and a capacity to effectively address these issues. To effectively address the issues, organisations must take a more proactive approach to workplace stress and review job demands for reasonableness, assess workplace relationships for collegiality and professionalism, determine if work hours are family-friendly and flexible, and facilitate opportunities for career progression (Jane-Llopis et al., 2011). Ideally, a healthy workplace will give a sense of security and allow appropriate professional creativity and autonomy. With mental health nurses leading these activities, issues around professional identity—and resilience—will very soon resolve themselves. Finally, stress management programs for individuals, teams, and professional groups may be helpful for the development
of skills for coping and contribute to enhanced professional resilience (Gillespie et al., 2007). Available options include enabling mental health nurses to participate in programs like REsilience and Activity for every DaY (READY), which provides participants with support and opportunities to further develop and improve psychosocial functioning and well-being (Burton et al., 2010); or organizing a facilitated resilience strengthening program such as PAR (Promoting Adult Resilience) (Millear, Liossis, Shochet, Biggs, & Donald, 2008). PAR has been developed for the workplace and aims to enhance self-efficacy with a series of structured sessions that draw on interpersonal and cognitive behaviour therapy principles within a supportive peer group. It is a strengths-based program building on preexisting participant skills. Participants practice skill improvement in areas such as communication, self-awareness, and appraising and handling problem situations. The program involves work-focused interpersonal exercises and allocates workbooks for individual homework. Trials have shown increases in selfefficacy, more work vigour, a greater sense of work mastery, and a better work-life balance (Millear et al., 2008).
CONCLUSION Whilst there is now a substantial body of work on the concept of resilience, in a variety of contexts, questions of what is required to make a resilient profession are still to be answered. This article commenced the process of exploration by examining the many changes experienced by the mental health nursing profession since de-institutionalisation. Notions of professional identity—including the need to be accepted, acknowledged, and to belong—are linked to professional resilience, as are the important role of leaders in taking the initiative and supporting activities to build resilience, heal the divisions, and continue to adapt to the ongoing changes that have characterised the last 30 years for the mental health nursing profession. We argue that strategies to enhance the collective professional resilience of mental health nurses could be developed to sustain and strengthen the professional identity of mental health nursing in Australia and across the globe. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES Altman Dautoff, D. (2001). Exploring individual and organizational resilience as factors in effective transient work teams. Dissertation Abstracts International Section A: Humanities and Social Sciences, 62(11-A), 1–24. Antonovsky, A. (1987) Health, stress and coping, San Francisco, CA: Jossey Bass. Ashby, S. E., Ryan, S., Gray, M., & James, C. (2013). Factors that influence the professional resilience of occupational therapists in mental health practice. Australian Occupational Therapy Journal, 60(2), 110–119.
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RESILIENCE: SUSTAINING MENTAL HEALTH NURSING Bajayo, R. (2012). Building community resilience to climate change through public health planning. Health Promotion Journal of Australia, 23(1), 30–36. Burton, N. W., Pakenham, K. I., & Brown, W. J. (2010). Feasibility and effectiveness of psychosocial resilience training: A pilot study of the READY program. Psychology, Health & Medicine, 15(3), 266–277. Castleden, M., McKee, M., Murray, V., & Leonardi, G. (2011). Resilience thinking in health protection. Journal of Public Health, 33(3), 369–377. Chapman, H. (1997). Self-help groups, family carers and mental health. Australian & New Zealand Journal of Mental Health Nursing, 6(4), 148–155. Cleary, M., & Happell, B. (2005). Promoting a sustainable mental health nursing workforce: An evaluation of a transition mental health nursing programme. International Journal of Mental Health Nursing, 14(2), 109–116. Cleary, M., Horsfall, J., Deacon, M., & Jackson, D. (2011). Leadership and mental health nursing. Issues in Mental Health Nursing, 32(10), 632–639. Cleary, M., Horsfall, J., & Happell, B. (2009). Transition to psychiatric/mental health nursing programs: Expectations and practical considerations. International Journal of Mental Health Nursing, 18(4), 265–273. Cleary, M., Horsfall, J., & Jackson, D. (2013). Role models in mental health nursing: The good, the bad, and the possible. Issues in Mental Health Nursing, 34, 635–636. Cleary, M., Horsfall, J., Mannix, J., O’Hara-Aarons, M., & Jackson, D. (2011). Valuing teamwork: Insights from newly-registered nurses working in specialist mental health services. International Journal of Mental Health Nursing, 20(6), 454–459. Cleary, M., Horsfall, J., O’Hara-Aarons, M., & Hunt, G. E. (2012). Mental health nurses’ views on therapeutic optimism. International Journal of Mental Health Nursing, 21(6), 497–503. Cleary, M., Horsfall, J., O’Hara-Aarons, M., Jackson, D., & Hunt, G. E. (2011). The views of mental health nurses on continuing professional development. Journal of Clinical Nursing, 20(23–24), 3561–3566. Cleary, M., Matheson, S., & Happell, B. (2009). Evaluation of a transition to practice programme for mental health nursing. Journal of Advanced Nursing, 65(4), 844–850. Cleary, M. L., Walter, G., Horsfall, J., & Matheson, S. (2009). A consideration of contemporary factors influencing professional development in health research. Journal of Continuing Education in Nursing, 40(6), 273–279. Crowther, J. A., & Ragusa, T. A. (2011). Realities of mental health nursing practice in rural Australia. Issues in Mental Health Nursing, 32(8), 512–518. Darbyshire, P., & Jackson, D. (2004–2005). Epilogue. Using a strengths approach to understand resilience and build health capacity in families. Contemporary Nurse: A Journal for the Australian Nursing Profession, 18(1–2), 211–212. Davidhizar, R., & Hart, A. (2006). Are you born a happy person or do you have to make it happen? Health Care Manager, 25(1), 64–69. Davies, H. T. O., Mannion, R., Jacobs, R., Powell, A. E., & Marshall, M. N. (2007). Exploring the relationship between senior management team culture and hospital performance. Medical Care Research and Review, 64(1), 46–65. Deacon, M., & Cleary, M. (2013). The reality of teamwork in an acute mental health ward. Perspectives in Psychiatric Care, 49(1), 50–57. Deveson, A. (2003). Resilience. Sydney, Australia: Allen & Unwin. Dolan, G., Strodl, E., & Hamernik, E. (2012). Why renal nurses cope so well with their workplace stressors. Journal of Renal Care, 38(4), 222–232. East, L., Jackson, D., O’Brien, L., & Peters, K. (2010). Storytelling: An approach that can help to develop resilience. Nurse Researcher, 17(3), 17–25. Edward, K. L. (2005). The phenomenon of resilience in crisis care mental health clinicians. International Journal of Mental Health Nursing, 14(2), 142–148. Edward, K., Welch, A., & Chater, K. (2009). The phenomenon of resilience as described by adults who have experienced mental illness. Journal of Advanced Nursing, 65(3), 587–595. Ely, R., & Roberts, L. (2008). Shift frames in team diversity research: From different to relationships. New York, NY: Cambridge University Press. Gallos, J. V. (2008). Learning from the toxic trenches: The winding road to healthier organizations and to healthy everyday leaders. Journal of Management Inquiry, 17(4), 354–367.
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Gibson, C. A. (2010). An integrated approach to managing disruption-related risk: Life and death in a model community. Journal of Business Continuity & Emergency Planning, 4(3), 246–261. Gillespie, B. M., Chaboyer, W., Wallis, M., & Grimbeek, P. (2007). Resilience in the operating room: Developing and testing of a resilience model. Journal of Advanced Nursing, 59(4), 427–438. Goleman, D. (1996). Emotional intelligence. Why it can matter more than IQ. London, UK: Bloomsbury. Grafton, E., Gillespie, B., & Henderson, S. (2010). Resilience: The power within. Oncology Nursing Forum, 37(6), 698–705. Happell, B. (2009). Turning the coin—Emphasizing the opportunities in mental health nursing. Issues in Mental Health Nursing, 30(10), 611–614. Henman, L. (1998). The Vietnam prisoner of war experience: Links between communication and resilience. Dissertation Abstracts International: Section B: The Sciences and Engineering, 59(5B), 2484. Hodges, H. F., Keeley, A. C., & Troyan, P. J. (2008). Professional resilience in baccalaureate-prepared acute care nurses: First steps. Nursing Education Perspectives, 29(2), 80–89. Holmes, C. (2001). Guest editorial. Journal of Psychiatric & Mental Health Nursing, 8(5), 379–381. Hungerford, C. L., & Hodgson, D. (2013). Addressing mental health nursing workforce needs in Australia: A case study analysis. Journal of Mental Health Training, Education and Practice, 8(2), 89–102. Isaacson, N., & Ford, P. (1998). Leadership, accountability, and wellness in organizations. Journal of Physical Therapy Education, 12(3), 31–38. Jackson, D. (2008). Servant leadership in nursing: A framework for developing sustainable research capacity in nursing. Collegian, 15(1), 27–33. Jackson, D., Firtko, A., & Edenborough, M. (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: A literature review. Journal of Advanced Nursing, 60(1), 1–9. Jackson, D., & O’Brien, L. (2013). The effective nurse. In (R. Elder, K. Evans, D. Nizette, Eds.) Psychiatric and Mental Health Nursing (3rd ed.). Chatswood, New South Wales: Mosby Elsevier. Jane-Llopis, E., Anderson, P., Stewart-Brown, S., Weare, K., Wahlbeck, K., McDaid, D., . . . Litchfield, P. (2011). Reducing the silent burden of impaired mental health. Journal of Health Communication, 16(Suppl. 2), 59–74. Jensen, P. M., Trollope-Kumar, K., Waters, H., & Everson, J. (2008). Building physician resilience. Canadian Family Physician, 54(5), 722–729. Keeney, S., Hasson, F., & McKenna, H. (2011). The Delphi technique in nursing and health research. London, UK: Wiley-Blackwell. Keshavarzi, S., & Yousefi, F. (2012). The relationship between emotional intelligence, spiritual intelligence, and resilience. Journal of Psychology, 16(3), 299–318. Khadjehturian, R. (2012). Stopping the culture of workplace incivility in nursing. Clinical Journal of Oncology Nursing, 16(6), 638–639. Kinman, G., & Grant, L. (2011). Exploring stress resilience in trainee social workers: The role of emotional and social competencies. British Journal of Social Work, 41(2), 261–275. Klohnen, E. C. (1996). Conceptual analysis and measurement of the construct of ego-resiliency. Journal of Personality and Social Psychology, 70(5), 1067–1079. Koen, M. P., van Eeden, C., & Wissing, M. P. (2011). The prevalence of resilience in a group of professional nurses. Health SA Gesondheid, 16(1). doi: 10:4102/hsag.v16i1.576 Manion, J. (2003). Joy at work! Creating a positive workplace. Journal of Nursing Administration, 33(12), 652–659. McDonald, G., Jackson, D., Wilkes, L., & Vickers, M. H. (2012). A work-based educational intervention to support the development of personal resilience in nurses and midwives. Nurse Education Today, 32(4), 378–384. McIlrath, C., Keeney, S., McKenna, H., & McLaughlin, D. (2010). Benchmarks for effective primary care-based nursing services for adults with depression: A Delphi study. Journal of Advanced Nursing, 66(2), 269– 281.
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McKenna, H., Keeney, S., & Bradley, M. (2003). Generic and specialist nursing roles in the community: An investigation of professional and lay views. Health & Social Care in the Community, 11(6), 537–545. Millear, P., Liossis, P., Shochet, I. M., Biggs, H., & Donald, M. (2008). Being on PAR: Outcomes of a pilot trial to improve mental health and well-being in the workplace with the promoting adult resilience (PAR) program. Behaviour Change, 25(4), 215–228. Nucifora, F., Jr., Langlieb, A. M., Siegal, E., Everly, G. S., Jr., & Kaminsky, M. (2007). Building resistance, resilience, and recovery in the wake of school and workplace violence. Disaster Medicine and Public Health Preparedness, 1(1 Suppl), S33–S37. Pfefferbaum, R. L., Pfefferbaum, B., Van Horn, R. L., Klomp, R. W., Norris, F. H., & Reissman, D. B. (2013). The communities advancing resilience toolkit (CART): An intervention to build community resilience to disasters. Journal of Public Health Management and Practice, 19(3), 250– 258. Pines, E., Rauschhuber, M., Norgan, G., Cook, J., Canchola, L., Richardson, C., & Jones, M. (2012). Stress resiliency, psychological empowerment and
conflict management styles among baccalaureate nursing students. Journal of Advanced Nursing, 68(7), 1482–1493. Seville, E., Brunsdon, D., Dantas, A., Le Masurier, J., Wilkinson, S., & Vargo, J. (2008). Organisational resilience: Researching the reality of New Zealand organisations. Journal of Business Continuity & Emergency Planning, 2(2), 258–266. Sousa, C., Haj-Yahia, M., Feldman, G., & Lee, J. (2013). Individual and collective dimensions of resilience within political violence. Trauma, Violence & Abuse, 14(3), 235–254. Stevens, J., Browne, G., & Graham, I. (2013). Career in mental health still an unlikely career choice for nursing graduates: A replicated longitudinal study. International Journal of Mental Health Nursing, 22(3), 213–220. Walsh, F., Cleary, A., & Dowling, M. (2012). Maximising psychiatric nurses’ contribution to interdisciplinary working. British Journal of Community Nursing, 17(6), 270–275. Warelow, P., & Edward, K. L. (2007). Caring as a resilient practice in mental health nursing: Feature article. International Journal of Mental Health Nursing, 16(2), 132–135.
Mental Health Nursing in Australia: Resilience as a Means of Sustaining the Specialty Michelle Cleary, RN, PhD∗ National University of Singapore, Yong Loo Lin School of Medicine, Singapore
Debra Jackson, RN, PhD Issues Ment Health Nurs Downloaded from informahealthcare.com by Nyu Medical Center on 04/19/15 For personal use only.
University of Technology, Faculty of Health, Sydney, NSW, Australia
Catherine L. Hungerford, RN, PhD∗ University of Canberra, Disciplines of Nursing and Midwifery, Faculty of Health, Canberra, Australia
dividual characteristic that supports an individual to withstand, adapt to, and develop in the face of change (Grafton, Gillespie, & Henderson, 2010; Koen, van Eeden, & Wissing, 2011). Others suggest resilience can be learned or developed, with resilient behaviours and practices an important means of assisting individuals to transcend and transform negative experiences into positive self-enhancing learning (Hodges, Keeley, & Troyan, 2008; Nucifora, Langlieb, Siegal, Everly, & Kaminsky, 2007; Warelow & Edward, 2007). Resilience also has been categorised according to context. There is personal resilience (Gallos, 2008; Grafton et al., 2010; Koen et al., 2011), workplace resilience (Cleary, Horsfall, & Jackson, 2013; Deacon & Cleary, 2013; Jackson, Firtko, & Edenborough, 2007), organisational resilience (Altman Dautoff, 2002; Gibson, 2010; Seville et al., 2008), community resilience (Bajayo, 2012; Pfefferbaum et al., 2013), and professional resilience (Ashby, Ryan, Gray, & James, 2013; Hodges et al., 2008). Resilience also has been positioned as a quality that can be nurtured by individuals and used to mitigate workplace adversity (Jackson et al., 2007). Few studies, however, have defined or considered the notion of group or collective resilience of a profession, including the capacity of that profession to withstand adversity and continue to develop positively in the face of change. This article considers the notion of resilience from the perspective of the specialty of mental health nursing in the Australian context, including the ways the specialty has adapted—and continues to develop—to changes since deinstitutionalisation. Insights are drawn from a national Delphi study undertaken in Australia to develop a Scope of Practice for Mental Health Nurses, with responses used as a springboard to consider the impact of the perceived loss of professional identity on the collective resilience of the profession. Although this article focuses on the Australian situation, we believe that the
As a concept, resilience is continuing to attract considerable attention and its importance across various life domains is increasingly recognised. Few studies, however, have defined or considered the notion of the group or collective resilience of a profession, including the capacity of that profession to withstand adversity and continue to develop positively in the face of change. This article considers the notion of resilience from the perspective of the specialty of mental health nursing, including the ways the specialty has adapted— and continues to develop—to changes experienced since deinstitutionalisation. Insights are drawn from a national Delphi study undertaken in Australia to develop a Scope of Practice for Mental Health Nurses, with responses used as a springboard to consider the impact of the perceived loss of professional identity on the collective resilience of the profession. Recommendations for a way forward for the profession are considered, including the ways in which a collective professional resilience could be developed to sustain and strengthen the professional identity of mental health nursing in Australia and across the globe.
As a concept, resilience is continuing to attract considerable attention and its importance across various life domains is increasingly recognised. Definitions of resilience are wideranging and the concept is conceptualised in various ways. Some view resilience as a power within—an innate and inThe authors acknowledge the assistance of Donna Hodgson (ACT Health) and Peta Marks (Australian College of Mental Health Nurses), the support of Kim Ryan (Australian College of Mental Health Nurses) and Rhonda Wilson (University of New England) in relation to the Scope of Practice Project, and Dr. Jan Horsfall for her review of an earlier draft of the paper. ∗ These two authors contributed equally to this article. Address correspondence to Michelle Cleary, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597. E-mail: [email protected] or michelle [email protected]
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recommendations arising from the study provide a potential way forward for the specialty internationally, and argue that collective professional resilience can be developed to sustain and strengthen the professional identity of mental health nursing across the globe.
A CHANGING PROFESSION The advent of deinstitutionalization in Western nations brought about a number of significant changes not only for health professionals, but also for people living with a mental illness, their care givers and other family members, and the community. For example, there has been a transformation of the psychiatric nurse into the mental health nurse, with a greater focus on health and wellness rather than illness and pathology (Chapman, 1997). Although this change in positioning has provided many more opportunities for mental health nurses, including expanded and extended roles in the community and primary health contexts, it also has led to a departure from or, perhaps, less recognition of the more traditional and perhaps definitive roles (Walsh, Cleary, & Dowling, 2012). Achieving such a significant transformation has required considerable flexibility and adaptability for the mental health nursing specialty as a whole. In Australia, major changes in national policy gave rise to the dual process of de-institutionalisation and the mainstreaming of mental health services into the general health care system from the 1970s. For mental health nurses, these changes generated a number of issues. Of particular concern has been the issue of the recruitment and retention of nurses to work in the field of mental health, together with high levels of stress and burnout (Cleary & Happell, 2005; Cleary, Horsfall, & Happell, 2009; Cleary, Matheson, & Happell, 2009; Jackson & O’Brien, 2013). Happell (2009) linked these issues to a diminution in the standing and appeal of mental health as a field of practice for nurses, and positioned this as a consequence of changes in the way in which mental health nurses are currently educated and regulated (similarly, Stevens, Browne, & Graham, 2013). These changes meant that mental health nursing ceased to have a unique registration (e.g., psychiatric, mental retardation). Currently, all registered nurses in Australia, irrespective of specialty area, are required to complete a generic Bachelor of Nursing degree, which means that all newly graduated registered nurses are considered to be eligible to enter the specialist mental health nursing environment. Indeed, national legislation does not require registered nurses to hold a specialist qualification to work in the field of mental health. This loss of a separate registration for mental health nurses has created uncertainty for many people, including other nurses and health professionals, as to the precise nature of the work of the mental health nurse; how this work is different to other nurses; and whether the mental health nursing is, indeed, a specialty in its own right (Holmes, 2001; Crowther & Ragusa, 2011). It should be noted however, that there are still nurses working in mental health
settings who were prepared within the hospital-based system and awarded the qualification of Registered Psychiatric Nurse (RPN). This qualification is recognised for registration, but the education pathway specific to mental health via hospital training has not been an option since the early 1980s. Instead, specialist mental health qualifications (graduate diploma, masters or doctorate) must now be obtained by registered nurses by undertaking tertiary-level study. This system has many differences compared to other countries. For example, in the United States, nursing is considered to be both a profession and a discipline, with psychiatric-mental health nursing being a nursing specialty.
DEFINING THE PROFESSION In response to the widespread uncertainty generated by deinstitutionalization and changes in the education and registration of mental health nurses, the peak professional body for mental health nurses in Australia, the Australian College of Mental Health Nurses, supported the conduct of an ethics committeeapproved National Scope of Practice Project in 2012–2013, with a view to more precisely describe the work of the contemporary mental health nurse. The Delphi Method is a structured approach to research that has been used extensively in the field of health to develop policy, scopes of practice, and practice frameworks (Keeney, Hasson, & McKenna, 2011; McIlrath, Keeney, McKenna, & McLaughlin, 2010; McKenna, Keeney, & Bradley, 2003). It comprises a number of stages, with each building on the previous stage, and utilizes a purposive sample of experts who collaboratively examine a particular topic, issue, or question and together mediate agreement on the meaning of this topic, issue, or question to generate new knowledge (McKenna, Keeney, & Bradley, 2003). The national Scope of Practice Project utilised four rounds, with the first round comprising a purposeful sample of registered nurses who had worked in the field of mental health for at least three years. A total of 1,162 registered nurses from across Australia participated in this round of the project. Each of these nurses was asked to provide feedback on a draft document that had been developed from a range of sources, including published research findings and policy documents; the draft document described the scope of practice of mental health nurses, as individuals and also collectively. The first round of the survey asked participants to respond to 14 statements related to scope of practice. The first question related to each statement used a Likert-type scale, with 1 being the rating for statements that participants’ considered of little importance and 10 being the rating for statements with substantial importance. The second question related to each statement asked participants to provide more feedback about the statement, if they wished, using an open-text response. Completion rates of the questions related to the first question ranged from 832 (68.5%) to 1,004 (82.7%), with these responses averaging 878 (72%). Response rates to the open-ended questions, the
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second question attached to each statement, ranged from 61 (5%) to 236 (20%), with the average number being 138 (11.8%).
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Who Are We? Although the majority of participants concentrated on providing feedback on the specific questions asked about the scope of practice of mental health nurses, a small number of participants used the opportunity as a platform to express how past, and more recent, structural changes in the mental health nursing profession have affected individuals. Many of these comments relate to notions of identity and a need to belong or feel accepted—and also showed some division within the profession: For me, being listed as an RN [Registered Nurse] instead of an RPN [Registered Psychiatric Nurse] has had a huge impact on my identity, as it has on a lot of nurses . . . We are no longer acknowledged for the profession we trained in!
Participants also identified outcomes of this loss of identity and lack of acknowledgement: The fact that all RNs can now work in mental health without mental health education or training has lost RPNs from the profession!
This loss of identity had caused some respondents to consider leaving the profession. In addition to leaving the profession, some nurses also described an awareness of their loss of commitment to supporting newly graduated nurses: The lack of respect from RNs towards us RPNs is why many of us will no longer supervise new grads, which is always vital in practice.
Others, again, noted an increase in the blurring of roles, the result of a new emphasis on the multidisciplinary team, and the impact of this on the mental health nursing specialty: The profession of mental health nurses needs to be recognized as its own specialty, instead of getting lost or confused within the allied professional scope. More and more community mental health roles are no longer specific but generic positions, as if allied health [professionals] have the same training and speciality as mental health nurses! This takes away from the mental health nursing profession!
Perhaps most significant was feedback expressing the alternative position, which suggests that many respondents felt they don’t belong or have not been welcomed into the mental health nursing fold: They sneer at me because I’m comprehensively educated. Apparently, if you haven’t done your time in “the bins,” you’re second rate! I’m sick and tired of the number of conferences I’ve attended where “Mary Smith” is lauded because she has worked in mental health for 30+ years. Apparently longevity is the only real badge of honour. Having a degree doesn’t seem to count. They stare down their noses at us and all I can think is . . . “Get over it and get with the times!” I’ve stopped going to the mental health nursing conferences—why line up to be marginalised by your so-called colleagues?
Clearly, a situation in which nurses practicing in the field do not feel fully accepted by colleagues has the potential to substan-
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tially weaken the profession. The need to address these identity issues was quite succinctly captured by one respondent: There needs to be an absolute identity re-established to recognize the mental health nursing profession!
Without this recognition, with this “absolute identity” that would enable mental health nurses to connect to one another, to be part of the group, to belong, one participant foresaw the gradual demise of the profession. This raises the question of how the mental health nursing profession as a whole will withstand, adapt to, and develop in the face of the quite significant changes experienced over the past few decades. Whilst a definitive scope of practice for mental health nurses suggests one way forward, it is not the only answer. This is because the scope of practice of mental health nurses encompasses a wide range of nursing and health care roles and functions; with diversity needed to promote optimal physical and mental health, prevent physical and mental illness, and support the physical and mental health preferences and needs of individuals, communities, and population groups. Moreover, the scope of practice of mental health nurses, like all nurses, will change and develop over time, in response to a range of contextual factors. Findings from this round of the study raised some very interesting questions about resilience in relation to mental health nursing. In the face of considerable and ongoing change, how resilient is the mental health nursing profession? Or, perhaps more importantly, how can the profession develop the levels of resilience required to meet the challenges at hand? RESILIENCE AND MENTAL HEALTH NURSES There is scant discussion in the literature related to the resilience of a profession. Over 20 years ago, Isaacson and Ford (1998) discussed notions of professional resilience in the context of organisational theory and recommended a redefinition of leadership where activities are distributed across the members of a group (rather than confined by hierarchical positioning or personal characteristics) to support the health and wellness of that group. Integrated into this horizontal model of leadership was the concept of ongoing learning at the individual and group levels, to increase the capacity of everyone to address problems as they arise. More recently, Ashby et al. (2013) identify a dynamic relationship among professional identity, professional practice, and professional resilience, and argue that professional resilience is sustained by strategies to maintain professional identity. These strategies include health professionals participating in clinical supervision, establishing support networks, and finding employment that allows a match between valued knowledge and opportunities to use that knowledge in practice. This notion of professional resilience, however, seems more aligned with the individual as a professional person, rather than the collective resilience of a profession as a whole. In light of the notion that an
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organisation or group is more than the sum of the parts, or members of the organisation or group, the notion of the collective resilience of the group requires a more focussed consideration. Personal Resilience The concept of personal resilience overlaps with the associated notions of having self-efficacy; tolerating ambiguity; having self-awareness; making meaning out of disorder; demonstrating realistic perseverance; and having the ability to analyse and appraise a situation, the tendency to interpret change or obstacles as manageable challenges, and the capacity to access relevant support (Grafton et al., 2010; Koen et al., 2011). Adequately resilient people are generally able to flexibly draw on a range of inner and outer resources and problemsolving strategies to manage and recover from stress or adversity (Antonovsky, 1987; Burton, Pakenham, & Brown, 2010; Kinman & Grant, 2011; Klohnen, 1996). Personal resilience also has been described as a continuum of adaptability that includes a range of capacities that allows people to manage change and diverse demands in their private and professional lives (Jackson et al., 2007). Moreover, personal resilience is not a fixed inherited dispositional characteristic and is, therefore, potentially amenable to strengthening by supporting individuals to “[recognise] choices for how to interpret and respond to events, keeping things in perspective, trusting one’s instincts, practicing new behaviours, and reflecting on the consequences” (Gallos, 2008, p. 363). Some have argued that resilience overlaps with the notion of emotional intelligence (Keshavarzi & Yousefi, 2012). The five domains of emotional intelligence outlined by Goleman (1996) are: emotional self-awareness; managing one’s own feelings so that they are not impeding; self-motivation in the service of goals; empathy—recognizing and respecting other people’s feelings; and social competence, which includes assertive communication and interpersonal responsiveness. People with welldeveloped emotional intelligence—that is, those who are empathetic and self-reflective—are likely to be more resilient under duress (Kinman & Grant, 2011) and “bounce back from adversity, persevere through difficult times, and return to a state of internal equilibrium or a state of healthy being” (Edward, 2005, p. 142). Typically, these resilient individuals will have clear boundaries, structured work routines, effective communication skills, good peer support networks, and they will be self-aware in that they are able to realistically recognize their strengths and limitations (Jensen, Trollope-Kumar, Waters, & Everson, 2008; Kinman & Grant, 2011). Professional Resilience Resilience also is dependent upon the fit between the individual and the context in which the individual is located. This includes the professional context. For example, the personal resilience of nurses is viewed as a valuable asset, because it can augment adaptability and practical and emotional well-being in
professional contexts that are often demanding and occasionally volatile (McDonald, Jackson, Wilkes, & Vickers, 2012). At the same time, however, professional resilience for nurses is by no means a “one size fits all” construct. For example, an individual mental health nurse may be resilient under stressors associated with high-adrenaline demands in a crisis or emergency setting, but be less resilient when working in a unit where most consumers are depressed and externally produced action is missing. This suggests connections between resilience and workplace satisfaction or enjoyment. Indeed, workplace satisfaction and enjoyment may well be a protective factor in the context of workplace adversity—as noted by Manion (2003), “[the way] we feel about and enjoy our work is crucial to how we perceive the quality of our lives . . . [but this] loss of joy is more than a personal issue; it is also an organizational issue” (Manion, 2003, p. 652). Promoting workplace enjoyment and satisfaction, however, is something of an art in today’s highly competitive and stressful workplace (Davidhizar & Hart, 2006). Hence, professional resilience is both an individual and organisational trait—and responsibility. Indeed, under present day circumstances, it is more strategic and effective for organisations to support and maintain employee resilience, than to re-develop resilience within the working group once it has waned. With resilience dependent upon the extent of the protection that is available to a person visa` -vis the level of adversity they are experiencing (Antonovsky, 1987), there is good reason to consider the role of employers and organisations in supporting professional resilience.
Group Resilience Definitions of group resilience are rare in the literature. Henman (1998) identified how interdependency, competition, structure, and supporting others to avoid apathy supported resilience in groups of prisoners of war in Vietnam. Altman Dautoff (2002) identifies the group attributes of flexibility, confidence to solve problems, and a common purpose, before going on to suggest that group resilience can be improved by building individual resilience skills, ensuring adequate resources are available for the group to achieve their goals, and providing acknowledgment and reward for group achievements. In contrast, definitions of community resilience in the literature abound. This category of resilience has been linked to notions of sustainability through people collaborating, sharing resources, and supporting one another to develop skills as they work towards a common goal (Bajayo, 2012; Castleden, McKee, Murray, & Leonardi, 2011; Pfefferbaum et al., 2013). Sousa, Haj-Yahia, Feldman, and Lee (2013) connect community resilience with optimism, hope, determination, and also a common values base. As a group, even community, the profession of mental health nursing can be described as a resilient group by virtue of its survival and continued development through the many, very substantial, internal and external changes experienced over the last few decades. A definition of this collective resilience can be
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drawn from the definitions of personal, professional, and group resilience provided above. This is because the mental health nursing profession is a composite of people with varying levels of personal and professional resilience. At the same time, the mental health nursing profession is much more than this; as a group, it is greater than the sum of its parts. To enable its own long term sustainability, then, the resilience of the profession will rest upon its own self-awareness, cooperation, acknowledgment of achievement and, perhaps most importantly, critical reflection. This must be combined with notions of hope, optimism, and determination to building a better profession for future generations. However, whilst such attributes provide a common goal to work toward, the more pragmatic questions also must be addressed. With the mental health nursing profession in Australia, and further afield, encompassing such a wide range of nursing and health care roles and functions, how can the collective resilience of this group be nurtured and developed?
TOWARDS BUILDING THE COLLECTIVE RESILIENCE OF THE MENTAL HEALTH NURSING SPECIALTY Koen et al. (2011) argue that resilience levels in groups of nurses and, by association, the profession as a whole, can be improved through the implementation of organisational and personal stress-management strategies. Promoting, supporting, and developing the collective resilience of the mental health nursing specialty, then, is the responsibility of the individual, employers, and professional bodies. By taking the initiative and exercising a horizontal leadership style to be proactive—all characteristics of resilient health professionals (Nucifora et al., 2007)—much can be done to foster professional resilience. Activities for Individuals A range of activities with the capacity to be adapted to meet the needs of the mental health nursing profession are recommended in the literature. For example, peer support is an important aspect of a cohesive group, demonstrating a willingness to provide support and guidance and also a valuing of others in the profession (Gillespie, Chaboyer, Wallis, & Grimbeek, 2007). Establishment of peer support networks, as well as opportunities for mentoring and skills-sharing, is something individual mental health nurses, employers, and also professional bodies can facilitate (Cleary, Horsfall, O’Hara-Aarons, Jackson, & Hunt, 2011; Cleary, Walter, Horsfall, & Matheson, 2009). Ideally, such networks would enable a sharing of responsibilities—together with the building and developing of personal, professional, and group bonds, both within and outside of the nurses’ immediate working environments. This would allow nurses to build supportive networks that support professional resilience locally and, by association, further afield (East, Jackson, O’Brien, & Peters, 2010; Jackson et al., 2007). Of particular note is the capacity of those involved to build and focus on the strengths, rather than the challenges, of the individuals and group; that is, identifying
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what is working for the mental health nursing profession rather than what is not (Darbyshire & Jackson, 2004-2005). Optimism has been identified as an important aspect of resilience for individuals (Deveson, 2003; Jackson et al., 2007) and is associated with building capacity in groups (Jackson, 2008). Research also shows that together with a cohesive culture that promotes participation, good staff morale, and a sense of commitment (Davies, Mannion, Jacobs, Powell, & Marshall, 2007), an inclusive group or team work approach (e.g., individuals sharing work, good communication, practical support) is essential for creating and maintaining optimistic and, by association, resilient professional groups (Cleary, Horsfall, O’Hara-Aarons, & Hunt, 2012; Deacon & Cleary, 2013). Teams get the work done in busy, sometimes chaotic mental health settings; teams also allow for camaraderie, sharing achievements, and fun. For this reason, wherever possible, it is important that individual mental health nurses work together in professional teams, supporting one another and, in so doing, developing a group identity. Effective leadership is crucial in fostering the growth of strong and resilient work teams, and in creating environments for community values to develop in work teams (Jackson, 2008). Strong and nurturing teams also will contribute to the development of future leaders within the profession, as well as supporting the role modelling of desirable mental health nursing behaviours (Cleary et al., 2013). Other ways the individual can promote team or group resilience are to welcome diversity, and treat each other in courteous and respectful ways, whilst appreciating difference and the capacity for each individual to make a unique contribution (Ely & Roberts, 2008). The “one size fits all” approach and the “but we’ve always done it this way” reflex have no place in a profession that is marked by a diverse and wide range of nursing and health care roles and functions (Cleary, Horsfall, Mannix, O’Hara-Aarons, & Jackson, 2011; Deacon & Cleary, 2013; Hungerford & Hodgson, 2013). Moreover, it is important that leaders of the profession challenge such attitudes. As noted by Dolan, Strodl, and Hamernik (2012), team building strategies can be used to promote an appreciation of differences in relation to education, experience, cultural background, and everyday work challenges as well as decrease prejudice and workplace discrimination or intra/professional marginalisation.
Activities for Managers It is important that managers—senior, middle and frontline—rise to the challenge of supporting the development of a resilient profession. As already noted, recruitment and retention of mental health nurses continue to be significant challenges for health services worldwide. Taking steps to build resilience into the profession, then, will value-add in the long term. Such steps may include the provision of providing positive, profession-enhancing experiences for employees (Warelow & Edward, 2007) together with ensuring appropriate support, including in-service education for mental health nurses, to better
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help them appropriately manage the many challenges they face in their working lives (Edward, Welch, & Chater, 2009). Further, managers need to apprise themselves of the quality of the workplace atmosphere for mental health nurses and also inter-professionally (Khadjehturian, 2012). Questions to be asked of the workplace may include: Is the unique role and work of the mental health nurse understood, valued, and respected in this environment? Are the concerns of mental health nurses being listened to, acknowledged, and responded to in timely and appropriate ways to support and maintain a healthy and enabling work milieu (Davidhizar & Hart, 2006)? Research findings show that when nursing work is acknowledged and appreciated, positive outcomes are more readily achieved (Cleary et al., 2012). This is not surprising, given that most people want to make a difference, engage in meaningful work activities, and make constructive contributions to achieve positive ends. At the same time, research findings also suggest the need for managers to be concerned with organisational justice, adequate workplace supports, and the use of communication styles, by all, that are respectful, clear, and encourage staff participation (Jane-Llopis et al., 2011).
Activities for Organisations From an organisational point of view, it is important to support the empowerment of the profession of mental health nursing, with empowerment closely related to resilience (Pines et al., 2012). For example, staff with some control over their job, flexible working arrangements, and a viable workload are more productive, and respond well to positive feedback and praise rather than externally imposed rules and fault-finding (JaneLlopis et al., 2011). Likewise, when mental health settings support leadership practices that are aligned with consumer-centred recovery, these setting will include mutual respect, effective communication, ethical practice, and a valuing of collaboration to create job satisfaction and improve morale, above and beyond good patient outcomes (Cleary, Horsfall, Deacon, & Jackson, 2011). For the mental health nursing profession, this suggests the value of individual mental health nurses taking the lead and demonstrating understanding of the issues involved and a capacity to effectively address these issues. To effectively address the issues, organisations must take a more proactive approach to workplace stress and review job demands for reasonableness, assess workplace relationships for collegiality and professionalism, determine if work hours are family-friendly and flexible, and facilitate opportunities for career progression (Jane-Llopis et al., 2011). Ideally, a healthy workplace will give a sense of security and allow appropriate professional creativity and autonomy. With mental health nurses leading these activities, issues around professional identity—and resilience—will very soon resolve themselves. Finally, stress management programs for individuals, teams, and professional groups may be helpful for the development
of skills for coping and contribute to enhanced professional resilience (Gillespie et al., 2007). Available options include enabling mental health nurses to participate in programs like REsilience and Activity for every DaY (READY), which provides participants with support and opportunities to further develop and improve psychosocial functioning and well-being (Burton et al., 2010); or organizing a facilitated resilience strengthening program such as PAR (Promoting Adult Resilience) (Millear, Liossis, Shochet, Biggs, & Donald, 2008). PAR has been developed for the workplace and aims to enhance self-efficacy with a series of structured sessions that draw on interpersonal and cognitive behaviour therapy principles within a supportive peer group. It is a strengths-based program building on preexisting participant skills. Participants practice skill improvement in areas such as communication, self-awareness, and appraising and handling problem situations. The program involves work-focused interpersonal exercises and allocates workbooks for individual homework. Trials have shown increases in selfefficacy, more work vigour, a greater sense of work mastery, and a better work-life balance (Millear et al., 2008).
CONCLUSION Whilst there is now a substantial body of work on the concept of resilience, in a variety of contexts, questions of what is required to make a resilient profession are still to be answered. This article commenced the process of exploration by examining the many changes experienced by the mental health nursing profession since de-institutionalisation. Notions of professional identity—including the need to be accepted, acknowledged, and to belong—are linked to professional resilience, as are the important role of leaders in taking the initiative and supporting activities to build resilience, heal the divisions, and continue to adapt to the ongoing changes that have characterised the last 30 years for the mental health nursing profession. We argue that strategies to enhance the collective professional resilience of mental health nurses could be developed to sustain and strengthen the professional identity of mental health nursing in Australia and across the globe. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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