International Journal of Emergency Mental Health and Human Resilience
Open Access

Resilience, Healthcare, Burnout, Delphi Study.

A nation’s health is dependent on the overall ‘health’ of its systems and processes of care. Being proactive in the measurement and response to the wellbeing of the HCP’s working within the UAE systems of care requires valid and reliable tools with which to measure the different variables understood to influence wellbeing, such as resilience. The lack of any culturally valid and reliable tool to measure resilience within the UAE demonstrates a significant challenge for local researchers. Any efforts to proactively modify the workplace environments and systems of care and provide learning opportunities for HCP’s to develop and/or sustain their resilience is therefore limited (Alharbi et al, 2020).

(Jackson et al) describe resilience as ‘a dynamic process encompassing positive adaptation within the context of significant adversity.’ The relationship between occupations and high suicide rates is reported to be the highest amongst those working in health professional roles, for both males and females (Meltzer, et al). Medical Council’s across the globe have recognized the need to promote resilience to reduce suicide in doctors and recommend that their medical schools provide their student with structured training in emotional resilience (Gerada et al, 2018).

Previous research about the enablers of resilience within HCPs has correlated low resilience to high rates of professional burnout and poor workplace retention (Cleary et al, 2014). Major international funders, such as the Medical Research Council and the Economic and Social Research Council in the UK have identified resilience as an important factor for lifelong health and well-being (Jackson, et al). Health system resilience is also widely researched and discussed in the literature (Bernard, 2019). There is debate however about whether the concept is well defined (Heritage et al, 2019). This has strong implications for improving knowledge about the factors that contribute to the development, maintenance or reduction of resilience and how resilience might be promoted to improve health and well-being. From the wider literature on personal resilience, professional resilience appears to be more than preventing ‘burning out’. Instead, resilience involves positive adaptation through the development of a variety of practices and behaviours that optimize an individual’s ability to cope (Braithwaite et al, 2016).

All the research to date on resilience has focused primarily on construct definition and measurement within a Western culture published a comprehensive systematic review of the available research literature (Cleary et al, 2018). Of the 33 studies that met the inclusion criteria and quality analysis, no study occurred within a UAE / Arab culture. As the healthcare systems within the UAE continue to expand and develop it is therefore important that efforts are made to establish a culturally valid understanding of the concept of resilience at both an individual and systems wide level. This research therefore adds new data to discussions on professional and health system strengthening, and how resilience can best be built and measured. Data generated from this research contributes to the UAE national strategic priorities of Tolerance, Compassion and Societal Happiness.

ETHICS APPROVAL: The study was reviewed and approved by the University of Wollongong’s Human Research Ethics Committee

Concept analysis is a method of knowledge representation and data analysis that is routinely applied in validation studies to clarify meaning and develop operational definitions. The application of this methodological framework enables a more objective approach to concept clarification and addresses differences across cultures. In order to ensure that most of the elements associated in the literature on resilience were considered during this study, a list of potential elements was constructed to help the expert panel determine which aspects of resilience were relevant to their experience of working in the UAE healthcare system. The list of elements was based on a systematic search of the literature followed by a 3-phase thematic analysis.

The search was carried out using a general search engine that included the following databases: EBSCO host, CINAHL, PUBMED, and Web of Science. The authors searched for peer-reviewed articles published between 2000 and 2020 containing the keywords: resilience, burnout, healthcare, teams, professional, workplace, hospital. The literature search resulted in a selection of 21 articles from which 203 stem statements were extracted. Each member of the research team independently analyzed these stem statements in an effort to identify commonalities - core themes. The team exchanged their individually identified themes and discussed differences, with the aim of achieving consensus on the type/ style of questions to be included in the survey (Table 1).

Table 1. Elements and Associated Criteria of Resilience

DELPHI METHOD: The Delphi method is a nonquantitative, iterative survey that has been successfully used for consensus building amongst subject matter experts (SME’s) on a specific concept (Kennedy, et al). Across three rounds of surveys the participating experts could indicate on a four-point scale (1=not important to 4=very important) how important each element was in relation to their lived experience of resilience in the UAE healthcare system. After responding to each element, the experts were asked if they thought the element could be better phrased. A free text box was available, after each question in the survey, for the participants to add any additional reflections, perspectives etc. In line with the Delphi methodology, after each successive round of the survey, the list of elements included in the next round of the survey were determine based on the percentage rating of each element during the previous round. The rules used for inclusion and exclusion of elements corresponds to other published and valid Delphi studies. The elements that were perceived as important by between 51 and 80% of the participants, were retained for reassessment during the next round of the Delphi study. Any additional elements that participants offered in the free text sections of the survey were critically analyzed by the research team. Whenever a free contribution was seen to be discreet from the 50 existing elements this element was added to the next round of the survey. This iterative process enabled the researchers to gather clarity on the participant’s (expert panel) consensus about the core elements comprising their experience of resilience for HCP working in the UAE healthcare setting. Elements that were not rated as important by at least 80% of the panel during the third round were classified as elements on which there was no consensus.

PARTICIPANT RECRUITMENT: In order to establish concept validation of resilience within the UAE healthcare environment a total of 30 UAE healthcare professionals were recruited to participate as the ‘panel of experts’ for the Delphi Survey. A snowball technique was used to identify suitable participants. The panel of experts consisted of healthcare professionals across a variety of healthcare settings (Table 2).

Table 2. Demographic of SME’s in Delphi Study.

At the time of the study (May 2020) the COVID19 pandemic was in full swing and the UAE healthcare system was straining to meet the demands presented by the pandemic. Similarly, healthcare professionals and healthcare systems were being challenged. The study was therefore delayed for 6 months as the research team did not want to burden the HCP with any additional demands. In addition, the increased pressure was anticipated to introduce the potential for negative bias in the HCP’s response to the survey. Ethics approval was sought and approved from the university x.

The first round was completed by 100% of participants (N=30). The gold standard for survey response rates is 60- 80% (Fincham et al, 2008). The second (96%) and third (90%) round of the survey the participant response rate continued to meet the gold standard. During the three rounds of the Delphi study the research team critically analyzed the participant’s free text contributions, resulting in 8 new elements being added to the original list of 50 (Table 3).

Table 3. Delphi panel results.

The decreasing number of elements in each round reflects the process of consensus building associated with the Delphi survey methodology (Table 3).

Elements that achieved a Top Box loading of 40% and above were included on the final list that represents the panel of expert’s consensus on resilience.

The elements that comprised the final survey, together with their assigned category and Top Box ranking are provided in (Table 4).

Table 4. Elements Included in Final Survey.

For the purpose of this study, elements that received a Top Box ranking of 40 % (N=8) and above were considered to reflect consensus of the expert panel on representing associated behaviours (indicators) of resilience for HCP working in the UAE healthcare sector. Each of these elements are analyzed within the context of existing research on resilience and discussed below.

Openly share thoughts & feelings with people I can trust received the highest level of consensus from the panel of experts with a Top Box rate of 69%. This element was included under the category / survey question: Strategies used to cope with difficult work environments/ experiences. This result is not surprising given the complex and high-risk environment that HCP work within. Having the opportunity to debrief with a trusted friend or colleague is key to managing adversity arising in the workplace (Jackson, et al) (Imani et al 2018) in their study on hospital nurses coping strategies found that sharing experiences and trusting that what is shared can remain confidential was a critical element of what they termed ‘Intelligent Resilience’.

Always greets me with a smile was the second highest element to achieve consensus with a Top Box rate of 63%. This element was included under the category / survey question: Behaviors in colleagues that demonstrate high resilience. Indeed, it requires immense physical and emotional resilience on the part of HCPs, to provide effective care to patients whilst maintaining a welcoming presences to both patients and their colleagues (Radhika, et al). From a service perspective, this behavior is highly valued and therefore an expected part of their professional persona (Radhika, et al) (Ting, et al) (Ying et al) (Walpita, et al).

However, it’s not uncommon for members of a team who are feeling overwhelmed to project these feelings onto their team members (Ting, et al) (McIntyre-Mills, et al) (Laskowski-Jones, et al) Joy at work has consistently demonstrated to be a necessary element of clinician wellbeing and engagement (Matheson, et al). This category of question achieving the second highest result in this Delphi study substantiates the results of (Matheson, et al) research which affirms the influence that an individual’s behaviour has on team performance. The SME’s for this Delphi study agreed that the simple act of offering a smile or sharing kind words between co-workers affects an individual’s ability to cope during highly stressful and chaotic times.

Lack of leadership support scored a Top Box rate of 56%. This element was included under the category / survey question: Challenges to your level of resilience in workplace. More than 30 years of research on the role leaders have on affecting team performance affirms the SME’s choice to include lack of leadership support as a key challenge on a team and therefore individual’s level of workplace resilience. A leader who is difficult to communicate with and/or approaches errors in the workplace from the perspective of ‘finding someone to blame’ creates a culture of fear - often resulting in a team that lacks psychological safety (Murray, et al). Efforts to listen, protect, prepare, support, when undertaken with authenticity, can facilitate the forming of authentic relational bonds that have proven fundamental for staff wellbeing (Shanafelt, et al). Resilience it not only an individual quality but a state of wellbeing that arises from within a workplace environment of psychological safety. A workplace where the leadership provides ready access to resources needed to support their team’s mental health and wellbeing proves important in optimizing workplace resilience (Giordano et al, 2019).

Focused under Pressure scored a Top Box rate of 53%. This element was included under the category / survey question: Examples of High Resilience. The ability to navigate complex challenges and adversity without losing focus is required for HCP’s not to lose confidence in their ability to practice safely. According to (Lanz, et al) the relationship between focus and resilience plays a significant role on influencing a nurses’ desire to stay or leave their profession. According to Plowe (Plowe, et al), resilience is a learnt behaviour - both a process and an outcome that is modifiable through education and practice.

Avoid Challenging Situations scored a Top Box rate of 50%. This element was included under the category / survey question: Example of Low Resilience. Individual caregivers depend on their team in order to provide safe and effective care. Members of a team who are feeling overwhelmed will struggle to get through the day, let alone offer support to their fellow caregivers. Several authors argue that living and working with challenging situations can lead to burnout, high turnover, and HCP’s leaving the profession (Kälvemark, et al) (Nordam, et al). (Robertson, et al) research demonstrated a positive correlation between high persistence, high selfdirectedness, and low avoidance of challenges. The 50% score represents the SME’s agreement that providing safe and effect care is a ‘team effort’ and therefore members of the team who avoid helping other team members cope with difficult situations is a clear indicator of low resilience (Mohanty & Wetherell, 2010).

I discuss challenges to find solutions with trusted friends scored a Top Box rate of 47%. This element was included under the category / survey question: Strategies used to cope with difficult work environments. This result is not surprising given the important role that psycho-social factors such as friendship, family bonds and regular leisure time have in optimizing a person’s level of resilience (Matheson, et al). (Murray, et al) argue that effective collaboration occurs in an atmosphere of mutual trust and respect. An important source of stress release in the workplace is the ability to share your experience with someone you can trust and in doing so learn that you are not alone in how you feel. Such sharing of experience provides a valuable opportunity for self-reflection which in turn opens up the possibility to see the situation/ experience from a different perspective and in doing so gain insight into how you might manage a similar situation in the future (Plowe, et al) (Rajamohan, et al) (Richez, et al) (Rushton, et al).

Easily get annoyed or lose my temper with friends or loved ones scored a Top Box rate of 44%. This element was included under the category / survey question: Warning signs that resilience is low. Given that resilience is the ability to cope with challenges and withstand pressure, individuals who succumb to outburst of anger and/or loss of temper is an overt sign of ineffective coping strategies. Numerous observational studies undertaken during the recent COVID19 pandemic describe the emotional and cognitive roller coaster. Scared and afraid, a sense of isolation, anger, betrayal, overwhelmed and exhaustion drove many otherwise resilient HCPs to get easily annoyed or lose their temper with their fellow team members.

I believe in myself and my abilities scored a Top Box rate of 40%. This element was included under the category / survey question: Strategies used to cope with difficult work environments. I believe in myself is a statement of self-efficacy. An individual’s belief that they can achieve a desired goal. Within the context of a healthcare setting, these goals relate to a professional’s scope of practice; their ability to meet the competency standards required to ensure high quality, safe and effective care to their assigned patients. A significant amount of resilience research highlights the importance of a person’s optimism to overcome the challenges they face and in doing so develop a greater sense of self-efficacy – a belief they will effectively manage similar challenges in the future (McIntyre‐Mills, 2022).

The aim of this Delphi study was to explore the extent to which the 50 elements presented in the survey as criteria to measure the level of resilience match those that healthcare professionals working in UAE perceive as important. To a large extent the findings of this Delphi Survey reflect the international literature – as there were only minor suggestions for additional elements to be included, most notably compassionate toward others as a measure of high resilience. Each of the 8 elements that garnered the highest level of consensus amongst the panel have a common theme of relationality. Reaffirming that HCPs level of resilience is largely dependent on the teams they work within. Research has shown us that an individual’s identity is intimately connected to their feelings and the perceived authenticity of relationships in their everyday worlds (Hollway, et al).Workplace cultures that erode the building and establishment of collegial relationships will result in the members of their team feeling isolated and vulnerable to increasing levels of stress and anxiety. The members of our expert panel agreed that having the opportunity to openly share thoughts and feelings with people they can trust is a key factor influencing their level of resilience within the workplace setting.

The panel members did not reach a consensus on all the elements found in the literature. The lack of consensus regarding reduced quality of care as a measure of Challenges to your level of resilience in the workplace was a surprise to the researchers. This lack of consensus might be due to a difference in attitude between doctors, nurses and Allied Healthcare professionals with regard to what qualifies as quality of care. An alternate reason might be whether or not the respondent/participant approached the survey question from the perspective of an individual or a member of a team. As such, in future research, it may be beneficial to have discipline specific panels since this might lead to valuable findings by being able to rigorously compare the views of medical specialists and nurses. This observation highlights one of the limitations of our study. Although it offers interesting insights into healthcare professionals’ perceptions of workplace resilience, the generalisability of the results is limited due to our panel consisting of healthcare professionals working within the UAE healthcare sector. The Delphi methodology prescribes a panel consisting of experts on a topic and, as such, healthcare professionals with more than 2 years’ experience working in UAE were selected for the expert panel.

Another potential limitation of this study is that the literature selection might bias the participants to consider resilience from a predefined perspective. The inclusion of the free text after each question was an effort to reduce this level of bias. However, since the elements extracted from the selected papers were broadly consistent, we do not see this filtering as likely to have led to the exclusion of important elements. Finally, it can be argued that the list of elements drawn from the publications was not definitive but merely served as the starting point for our Delphi study in which the panel could rephrase and add elements. Thus, overall, we would argue that the literature search met the needs of the study.

Although the list of elements was drawn up to form a basis for a discussion in which the panel would decide which elements were important in measuring the level of resilience within the workplace setting, there is a risk that its length would restrain the panelists from suggesting additional items. To counteract this danger, we stressed that the list should not be seen as complete. Further, given that some elements showed similarities to other elements, this ‘repetition’ combined with the length of the list might have led to the panel members losing interest. To counteract this, the first round of the study was carried out on a different day to the second and third rounds to counteract fatigue. The fact that the panelists did take the opportunity to add and rephrase elements we believe means we were successful.

To conclude, this research adds new data to discussions on professional and health system strengthening, and how resilience can best be built and measured. Data generated from this research contributes to the UAE national strategic priorities of Tolerance, Compassion and Societal Happiness by promoting clarity on the important concept of resilience which supports future researches in the design of tools to measure the level of resilience amongst HCP working in the UAE health system. Once valid assessment tools are developed researchers can then begin to measure the effectiveness of different strategies in increasing caregiver levels of resilience.

The author do not have any existing conflict of Interest

The author received no financial support for the research, authorship, and/or publication of this article.

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