4 Maintaining Resilience through Positive Collaborations

Providing compassionate care to patients/clients when they are at their most vulnerable can be physically and emotionally demanding for health-care professionals. Helping and caring for others involve a high degree of altruism. Although work in the helping professions provides limitless opportunities for satisfaction and personal growth, it can come at a personal cost. The extent to which skilful “self-giving” is required can cause suffering for caregivers (McAllister & McKinnon, 2009). When health-care professionals engage in self-giving, they might attend to the needs of others at the expense of taking care of their own physical and emotional needs. Carers might neglect their own health and view self-care as a low priority (Foureur et al., 2013).

Experiences of feeling burned out are common. The word burnout was initially defined as “a syndrome of emotional exhaustion, depersonalisation, and reduced personal accomplishment that can occur among individuals who work with people in some capacity” (Maslach et al., 1996, p. 4). In response to feeling burned out, people distance themselves emotionally as a form of self-protection (Maslach et al., 1996). The World Health Organization (2018) extended this seminal definition to emphasize that burnout also includes feelings of negativism or cynicism related to one’s job. Learners in clinical environments can expect to encounter health-care professionals who are experiencing some, if not all, of the negative emotions associated with burnout. For example, in a cross-sectional survey of nurses from 12 countries in Europe and the United States, 42% of the nurses described themselves as “burned out” (Aiken et al., 2012).

According to Grant and Kinman (2014), the emotionally demanding nature of work in health-care fields can also lead to secondary trauma (emotional distress associated with hearing about the first-hand trauma experienced by another), vicarious trauma (a damaging shift in beliefs about the world in response to being repeatedly exposed to traumatic material), and compassion fatigue (physical, mental, and emotional withdrawal associated with caring for sick or traumatized people especially if you are not able to relieve their suffering). Health-care professionals frequently experience psychological distress in relation to their role, the wider organizational context, a perceived lack of control, and interactions with patients/clients that evoke strong emotional reactions (Grant & Kinman, 2014).

Although compassion fatigue is a syndrome usually associated with the negative effects of providing care to the ill, there is emerging evidence that educators can experience a similar syndrome as they care about the success of students and come to know of stress and suffering among students that they are unable to relieve. Educators can be vulnerable to compassion fatigue since the teaching profession attracts individuals who gain satisfaction in caring for people (Krop, 2013; Showalter, 2010). Many who enter teaching as a profession are empathetic and nurturing individuals “whose personal identity is closely associated with their professional role” (Boyle, 2011, p. 1; Fowler, 2015; Hunsaker et al., 2015; Krop, 2013). Caring is often viewed as a fundamental value of the teaching profession. Educators might see their students’ success as their own in some ways (Isenbarger & Zembylas, 2006) and often come to care about the success and well-being of learners. Teachers can experience emotional labour as they teach, nurture, and guide individuals along their life paths for sustained periods of time, often years (Isenbarger & Zembylas, 2006). These factors make educators—especially those who genuinely care about their learners and aim to get to know them well—at risk of compassion fatigue.

The cost of caring is not limited to practising health-care professionals and educators. Learners can experience similar negative emotions. They can have strong emotional reactions to clinical placements, they can feel conflicted between their role as a learner and their role as an emerging professional, and they can perceive themselves as ineffective (Grant & Kinman, 2014). Many health-care learners experience feelings of depression (Rakesh et al., 2017). Learners are often reluctant to disclose that they are experiencing difficulties, exacerbating potentially damaging negative emotions (Grant & Kinman, 2014).

Like practitioners and learners, educators in health fields are also affected by the cost of caring. People who work in most areas of education are considered helping professionals, and they often give generously of themselves in their work with learners. Educators have frequently expressed that they feel extremely stressed (Thomas et al., 2019), overwhelmed by emotional demands, and as though they are merely surviving rather than thriving (Aguilar, 2018).

Given that clinical teachers straddle the fields of both health and education, they can expect to face ongoing personal challenges related to their own emotional health throughout their careers. At times, emotional depletion and negativity can distract from a view of teaching as fulfilling, enjoyable, and satisfying work. When educators in health fields do view their teaching as satisfying, they are more likely to do their work in an exemplary way (Melrose et al., 2020). An important first step that clinical teachers can take toward feeling less depleted and more fulfilled is intentionally to articulate the positive aspects of clinical teaching that are especially meaningful to them.

The cost of caring is further illustrated with an explanation of the term “emotional labour.” It refers to the process by which workers are expected to manage their feelings in accordance with organizationally defined rules and guidelines (Hochschild, 1983/2003). Emotional labour affects people who work in areas where there is intensive contact with the public and where people are expected to regulate their emotions during interactions with others (Hochschild, 1983/2003). Some workplace roles (including those in health and education fields) stipulate either formally or informally that certain emotions can be displayed publicly, whereas others are expected to be kept private. For example, expressing patience and empathy is considered appropriate, whereas showing frustration and disgust is not (Kinman & Leggetter, 2016).

Daily, health-care practitioners, learners, and clinical teachers all engage in emotionally charged contacts with patients/clients. In addition to those intense contacts, learners engage in equally intense interactions with practitioners and their clinical teachers, especially during evaluation activities. Certainly, appropriate responses are expected in public. Yet powerful emotions that are not considered appropriate to display are also present. The emotional labour expected of professionals requires that these emotions remain private. It is important to note that the notion of “private” does not mean that these emotions are to remain unacknowledged. Rather, it emphasizes the importance of finding suitable outlets for expressing certain emotions.

When people continue to work and learn in situations in which their need for emotional expression does not conform to workplace expectations of emotional labour (whether real or perceived), they can experience profound emotional strain and dissonance (Kinman & Leggetter, 2016). The effort required to keep emotions hidden below the surface and act well emotionally drains people of their emotional resources and leaves them feeling stressed, conflicted, depleted, mentally exhausted, and burned out (Delgado et al., 2017; Kinman & Leggetter, 2016). It adversely affects workplace interactions, workplace relationships, and ultimately workplace performance (Delgado et al., 2020). For those with limited experience in a caring role, navigating the demands of emotional labour inherent in the role of health-care professional can be particularly problematic (Kinman & Leggetter, 2016).

Believing that emotional regulation requires people to suppress their emotions is not healthy. Although health-care professionals would encourage their patients/clients to find respectful and appropriate ways to express their emotions (even those construed as negative), opportunities to do so might not be immediately available to the professionals themselves. As educators, it is critical to assess expectations related to emotional labour in the clinical settings in which students are learning. The rules and guidelines might be more implicit than explicit. Expressions of emotions that are viewed as inappropriate in one setting might be quite different in another. Not all members of staff groups will model healthy regulation of their emotions.

Recognizing and acknowledging that emotional labour (the ability to regulate emotions) is expected in professional fields is an important foundational step in helping learners to prepare for the realities of practice. Aspects of the topic are often addressed under curriculum concepts related to “professionalism.” To be fully informative, however, clinical teachers must instigate discussions of how to manage (and importantly to express) the negative feelings and responses that professionals inevitably experience in practice settings.

As the preceding discussion emphasized, the caring and emotional labour required of health-care professionals, learners, and clinical teachers alike affect their emotional well-being. Consistently expressing positive rather than negative emotions, together with approaching stressful workplace challenges as opportunities rather than setbacks, require ongoing efforts. Positive emotions are more than just being happy; they reflect a deeper approach to how life is experienced (Pipe et al., 2012; Tugade et al., 2004). Emotions that express positivity are those rich in joy, gratitude, serenity, interest, hope, pride, amusement, inspiration, awe, and love (Fredrickson, 2009). People who can display these kinds of positive emotions, even under difficult circumstances, are viewed as emotionally resilient.

The word resilience is defined as “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of stress” (American Psychological Association, 2014, para 4). Resilience is a multidimensional psychological construct that overlaps with other constructs, including organizational resilience and individual workplace resilience (Rees et al., 2015). Organizational resilience is an organization’s or institution’s ability and capacity to handle disruptive events (Ruiz-Martin et al., 2018). Individual resilience is an employee’s ability to handle adversity successfully (Hartmann et al., 2020). Not unexpectedly, people who work in highly resilient organizations have more opportunities to learn about and develop their individual resilience. A strong, supportive, and team-oriented culture can help health-care professionals to manage the emotional demands of their roles (Cheng et al., 2013).

In health-care settings, clinical teachers might have limited control over the level of organizational resilience demonstrated in the clinical environments in which their students learn. A culture of coping dominated by negativity and emotional distancing might be present in these places. The role models that learners are exposed to might not handle the cost of caring well, and they might struggle with the demands of emotional labour that their roles require of them. However, clinical teachers do control the extent to which they demonstrate their own resilience and how they invite learners to do likewise. A dimension of resilience that is well suited to instruction in clinical areas is emotional resilience.

It refers to the element of affect that is inherent in resilience. Emotional resilience is the ability to “recover” from adversity, react appropriately, or “bounce back” when life gets tough (Grant & Kinman, 2014). When applied to health-care workplace settings, emotional resilience is further explained as the ability to maintain personal and professional well-being in the face of ongoing work stress and adversity (McCann et al., 2013). Health-care professionals who have enhanced emotional resilience express less negativity and feel less overwhelmed by job stresses (McCann et al., 2013; Stacey & Cook, 2019).

Emotional resilience, like all forms of resilience, is not an innate, fixed characteristic; rather, it is a skill that can be developed and enhanced (Grant & Kinman, 2014; Stephens, 2013). Research suggests that integrating educational content and instruction in resilience can help learners in the health-care professions to feel stronger, more focused, and better able to endure negative emotions (Grant & Kinman, 2014; McAllister & McKinnon, 2009; Stacey et al., 2017). For example, when resilience competencies were integrated into a nursing curriculum, students thought that the self-care interventions that they learned increased their ability to provide compassionate care to patients (Stacey et al., 2017). Similarly, when resilience-building activities were included in their curriculum, student physicians found that they were better able to empathize with patients, combat stress and burnout, and gain awareness of ways to promote a culture of mutual openness and understanding (Rakesh et al., 2017). Furthermore, introducing emotional resilience strategies to social work students helped them to deal with the emotional demands of their profession (Grant & Kinman, 2014).

In their research exploring emotional resilience in practising and student social workers, Grant and Kinman (2014) identified how people who were able to adapt positively to stressful working conditions (and manage their emotional demands) demonstrated four competencies that are helpful in training students to become resilient professionals: reflective ability, emotional intelligence, social confidence, and social support. None of these competencies can be achieved by learners on their own. Collaborations and connections with others are required. Next we explain how clinical teachers can create the kinds of collaborations that will help learners to enhance these competencies.

Reflective ability can be enhanced when learners are provided with opportunities to reflect on their practice, consider their personal motivations, and explore the nature and impact of their interactions with others. Emotional intelligence (with which people are able to persist in the face of frustration, control impulses, delay gratification, establish emotional boundaries, avoid overinvolvement with patients/clients, and “accurately” empathize with others) can be enhanced when learners are provided with safe spaces in which to discuss their emotional responses to distressing events. Social confidence (e.g., demonstrating assertiveness and conflict resolution skills) can be enhanced when learners are encouraged to challenge instances of poor clinical practice and share appropriately the negative emotions that these poor practices evoke. Social support can be enhanced when learners are consistently invited to connect in meaningful ways with their educators, preceptors/practitioners, and fellow students.

Grant and Kinman (2014) further posit that specific approaches to developing the competencies in emotional resilience mentioned above can be grouped into the categories of reflective practice, supervision, and peer coaching. Although these approaches can be included in health professions curricula in other topic areas, the specific links to enhancing emotional resilience might not be identified.

Beyond ensuring that supervisory activities with learners include safe spaces, and that peer coaching/mentoring opportunities are available to learners, clinical teachers can enhance emotional resilience by strategically finding ways to cultivate positive collaborations. The interpersonal connections so necessary for health-care professionals to develop and maintain a positive and resilient outlook on their practice might not just happen. In the following discussion, we comment on how promoting civility, harnessing anxiety, and resolving conflict in a positive way can support positive collaborations.

In all of their collaborations with patients/clients and members of health-care teams, health-care profession learners are expected to demonstrate and promote civil (polite, courteous, and respectful) behaviour. Everyone expects to be treated by those in clinical workplaces with civility. Unfortunately, reports from institutions across many sectors, including those that provide health-care services, indicate a rise in incivility (Craft et al., 2020; Pattani et al., 2018).

In workplace environments, incivility is defined as low-intensity behaviours in either words or gestures that can confer indirect harm on colleagues and cultivate a toxic work culture (Pattani et al., 2018). Examples of incivility include eye-rolling, bullying, verbal abuse or rudeness, excessive competitiveness, social exclusion, inaction (e.g., not responding to emails), and other forms of disrespect (Pattani et al., 2018). Some serious manifestations of incivility, such as physical abuse and sexual harassment, violate the law (Zhu et al., 2019). Despite indications that incivility has negatively affected organizational operating costs, employee turnover, employee performance, group cohesion, and organizational commitment in health care (as well as other industries), problems with incivility continue to emerge in many workplaces (Porath & Pearson, 2013).

In academic settings, the definition of incivility is extended to include the notion that behaviours that interfere with the learning process are also considered uncivil (Robertson, 2012). Incivility can be demonstrated by students toward faculty or other students and by faculty toward students, other faculty, or administration. Examples of student incivility in classrooms and labs include disrupting class, using cellphones or computers for activities not related to class, carrying on side conversations during class, making negative remarks, challenging instructors inappropriately, pressuring faculty to meet their demands (e.g., increasing a grade), and dominating discussions (i.e., preventing other students from joining in them). Outside the classroom, students who act with incivility can discredit faculty; complain about them; speak negatively about their program; gossip about other students; demand make-up assignments, extensions, or grade changes; and fail to follow the appropriate lines of communication (Clark & Carnosso, 2008; Clark & Springer, 2007; Penconek, 2014, 2020).

Examples of faculty incivility toward students include challenging students’ knowledge in front of the class, belittling students in front of others, displaying favouritism, demonstrating inconsistency with evaluations, complaining about their profession, and not providing an open and secure forum for discussing concerns (Clark & Carnosso, 2008; Clark & Springer, 2007; Penconek, 2014). Faculty also demonstrate incivility when they arrive late for class, provide learners with unclear expectations, change or have a poorly constructed syllabus, or set a cold, unwelcoming, or disrespectful tone in the classroom or clinical setting (Robertson, 2012).

In clinical areas, examples of faculty and practitioner incivility include showing lack of professionalism in the workplace, being disrespectful and unfair toward students, and making students feel unwanted and ignored in the workplace (Zhu et al., 2019). When faculty behave in uncivil ways toward other faculty or administrators, they might refuse to answer questions, make condescending remarks or express “put-downs, ” indicate that they are unavailable, present a distant or cold demeanour, or exert rank or superiority (Clark & Carnosso, 2008).

When people in any setting experience incivility, they can leave the situation feeling highly distressed (Clark & Carnosso, 2008; Clark et al., 2009; Robertson, 2012). The negative feelings and emotional depletion can persist long after the incident has passed, making it difficult to remain emotionally resilient and find enjoyment in one’s career. When health-care profession students experience incivility in their academic or clinical education, they can leave their programs or be acculturated to become uncivil professionals (Milesky et al., 2015). Educators who experience incivility suffer anxiety and poor performance, and they might leave academia altogether (Milesky et al., 2015).

When incivility is present in clinical environments, it can spread to academic environments and vice versa. Incivility leads to toxic work environments that adversely affect patients/clients (Layne et al., 2019; Milesky et al., 2015; Pattani et al., 2018; Pronovost & Vohr, 2010). Clearly, any effort that clinical teachers can make toward understanding possible triggers of incivility and finding ways to promote civility is time well spent. A significant relationship exists between unmanaged job stress/anxiety (including difficulty resolving conflicts) and incivility in the workplace (Oyeleye et al., 2013).

In the following discussion, we comment on how techniques geared to harnessing anxiety and resolving conflict can begin to help learners strengthen their emotional resilience and collaborate successfully with those whom they encounter in clinical settings.

When practitioners, educators, and learners are burdened by heavy workloads, family responsibilities, and the emotional labour required of professionals, they can expect to feel anxiety at times. It can be displayed through inappropriate expressions of negative emotion and incivility. For learners, mild to moderate levels of anxiety can benefit learning, but high levels of anxiety result in decreased learning (Melincavage, 2011). High levels of anxiety in clinical environments can have profound impacts on learners’ personal lives and on their clinical performance (Melo et al., 2010; Turner & McCarthy, 2016).

Just as teaching approaches that emphasize reflective practice, supervision that includes safe psychological spaces, and structured activities in which peer coaching/mentoring occur can enhance emotional resilience, so too these approaches can harness learner anxiety. Self-reflection techniques help learners to mediate stress, gain insight, and learn appropriate coping behaviours (Eng & Pai, 2015). Supervision by clinical teachers that invites learners to share their preferred learning styles and to articulate anxiety management strategies that have worked for them in the past will help to lower their levels of anxiety. Peer coaching/mentoring in clinical environments can decrease anxiety and confusion among students, increase their positive educational environments, improve their responsibility, promote their active learning, enhance their involvement, and help to develop their ability to mentor in the future (Sprengel & Job, 2004).

Additionally, as health professionals themselves, clinical teachers have a repertoire of anti-anxiety management techniques that are effective with patients/clients. Modelling these techniques during high-stress interactions with students can have a positive and far-reaching influence. One such technique, mindfulness, is gaining increasing recognition as a way of regulating negative emotions, including anxiety.

Mindfulness, in relation to health professionals’ own emotional wellness, was initially conceptualized as a logical extension of the concept of reflective practice. Ronald Epstein (1999), a physician and leader in mindfulness techniques, defined mindfulness as a process of remaining present in everyday experiences and being open to all thoughts, actions, and sensations. This openness includes being cognizant of one’s own mental processes, being aware of what is occurring around oneself, and responding with acts of compassion (Epstein, 1999). In short, mindfulness calls professionals to attend intentionally in an open and discerning way to whatever arises in the present moment (Shapiro, 2009).

A growing body of research links mindfulness techniques to enhanced emotional well-being, and calls for integrating mindfulness training as a self-care strategy into health professions education programs are increasing (Foureur et al., 2013; Irving et al., 2009; Reid, 2013). Learning institutions that offer programs for health-care professionals can integrate mindfulness techniques, resources, and practice sessions into the curriculum. In these instances, students bring this foundational knowledge from the classroom directly to their clinical practice. In other instances, learning institutions can offer workshops or individual training sessions on mindfulness through their student services or counselling centres. Additionally, health-care organizations and clinical agencies can provide mindfulness training through their human resources or employee assistance programs. When clinical teachers are aware of resources related to mindfulness that are available to students, they can incorporate them into their clinical teaching and extend students’ existing knowledge.

Upon arrival in the clinical area, gather the group together in a quiet place (even the clean utility room). With gentle intonation, read or adapt the following script:

Close your eyes or soften your gaze and breathe in and out. With each breath in, breathe in strength, hope, and possibility. With each breath out, let go of fears, preoccupations, and burdens in your life. As you breathe more deeply, notice the breath soften the belly, opening the heart, making way for your gifts to come to the surface. Notice your feet on the floor, rooted—you are supported. At any point today, you can return to the breath softening the belly, opening the heart.

MARY ANN MORRIS, RN, MSN, SELKIRK COLLEGE

Conflict is inevitable in situations in which people must interact with one another in order to learn and work. Although professionals in the business fields have come to recognize conflict as a potential source of learning and innovation, professionals in the health fields still tend to view conflict through a negative lens, often considering it to be disruptive, inefficient, and unprofessional (Eichbaum, 2018). Consequently, many health professions practitioners and learners tend to avoid conflict or try to resolve it quickly.

When people disagree and argue, they are in conflict; however, when they reach an agreement, they are said to have resolved that conflict. Certainly, health-care professionals are not expected to resolve all disagreements. However, they are expected to engage in civil interactions that do not leave anyone involved feeling distressed and emotionally depleted. They can respectfully “agree to disagree.”

There is a plethora of conflict resolution theories and models, and health professions programs can adapt a specific model that learners are expected to use when conflicts arise in their academic or clinical environments. The model can be framed more from a problem-solving orientation than from a focus on conflict resolution alone. An important first step is for clinical teachers to familiarize themselves with any conflict resolution (or problem-solving) models with which learners have experience, either from their educational programs or from their life experiences. When the curriculum does not stipulate the use of a model, clinical teachers need to be prepared for conflicts and have simple yet effective tools in place to help those involved in the conflicts to face them positively and constructively.

One such tool is a model that the American Management Association (n.d.) suggests. The model is an efficient five-step process for resolving conflict. First, identify the source of the conflict. Make sure that all parties have the chance to share their side of the story. Second, look beyond the incident. Explore perspectives of events and problems that might have triggered the incident. Third, request solutions. Ensure that each party identifies their idea of how the situation could be changed or resolved. Fourth, identify solutions that all parties can support. Point out the merits of various ideas, not only from each other’s perspective, but also in terms of benefits to the organization. Fifth, reach agreement. Agree to an idea identified in the fourth step, possibly in the form of a written contract. Create a plan for what to do if problems arise in the future.

It is useful to introduce learners to whatever model will be used to resolve conflicts in their learning experiences before a distressing disagreement arises. Including an explanation of the model during orientation activities and commenting on how conflict is an expected and potentially positive aspect of clinical practice will normalize the experience. Just as collaborations that enhance emotional resilience, promote civility, and harness anxiety help health-care professionals to provide more compassionate care to patients/clients, so too when health-care professionals work toward resolving conflicting views patients/clients benefit once again (Ellis & Toney-Butler, 2019).

Nurturing an “attitude of gratitude” can prevent disagreements from escalating into distressing and emotionally depleting conflicts. Under-standing others’ perspectives is an important element of resolving conflict successfully. Cultivating and displaying positive emotions such as joy, optimism, and gratitude can help people to remain open to different ways of thinking and acting, even when they might not agree with these differences.

Research indicates that the positive emotion of gratitude is linked to lower levels of aggression and motivates people to express sensitivity to and concern for others (DeWall et al., 2012). Expressing gratitude can help people to feel less emotionally exhausted and cynical and more inclined to approach potential conflicts and problems proactively (Burke et al., 2009). A focus on positivity and gratitude shifts thinking away from negative emotions (Emmons & McCullough, 2003). In one health professions program, when faculty were introduced to gratitude interventions, they felt a deeper sense of appreciation for colleagues and more satisfaction with their jobs (Stegen & Wankier, 2018).

Gratitude can be construed as both an emotional response and a habit or coping response. In his work exploring gratitude, Robert Emmons (n.d.), the founding editor-in-chief of The Journal of Positive Psychology, encouraged people to view experiencing and expressing gratitude as a habit that can be developed and should be practised daily. He suggests establishing a daily practice of reminding ourselves of the good things that we enjoy, our personal attributes, and valued people in our lives and then recording them in a journal. When clinical teachers model an attitude of gratitude and invite students to do the same, they set a tone of reciprocal respect that enriches interactions and makes conflicts that emerge less onerous and emotionally damaging.

In this chapter, we discussed how maintaining resilience through positive collaborations can nurture feelings of fulfillment and passion. A career in the health professions, in which caring for others can be emotionally demanding, requires people to remain emotionally resilient. Connecting with others in meaningful ways can help those who provide care to others to receive needed emotional support themselves. Clinical teachers can cultivate successful collaborations with and among learners in everyday activities. Educators can intentionally provide safe spaces where learners are free to express their negative emotions as well as their positive emotions. They can encourage reflective practice, remain aware of the imbalance of power during supervision, and ensure that opportunities for connecting with like-minded others, such as fellow students, are available.

Importantly, during every interaction that clinical teachers engage in with learners, practitioners, patients/clients, and others in the clinical environment, they model the behaviour that they expect to see learners demonstrate. When clinical teachers use strategies that promote civility, harness anxiety, and resolve conflicts in their relationships with others, learners will assimilate these strategies into their own thinking.

In many instances, the personal connections with others sustain health-care professionals during times when they feel emotionally depleted. Guid-ing learners toward establishing successful collaborations will strengthen their emotional well-being, increase their feelings of satisfaction at work, and ultimately help them to provide compassionate care to patients/clients.

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