Collegian (2013) 20, 17—25

Available online at www.sciencedirect.com

jo ur nal homep age: www.elsev ier .com/ locate /co l l

Exploring resilience in paediatric oncology nursingstaff

Melissa Zander, RN, BaMedRad (RT), BNg, BNg (Hons)a,b,∗,Alison Hutton, RN, PhD, MRCNAa, Lindy King, RN, PhD, BN (Ed)a

a Flinders University, Bedford Park, South Australia, Australiab Flinders Medical Centre, Bedford Park, South Australia, Australia

Received 29 August 2011; received in revised form 4 December 2011; accepted 8 February 2012

KEYWORDSPaediatric oncologynursing;Stress;Coping;Resilience

Summary Resilience has been suggested as an important coping strategy for nurses workingin demanding settings, such as paediatric oncology. This qualitative study explored paediatriconcology nurses’ perceptions of their development of resilience and how this resilience under-pinned their ability to deal with work-related stressors. Five paediatric oncology nurses wereinterviewed about their understanding of the concept of resilience, their preferred copingmechanisms, and their day-today work in paediatric oncology.

Using thematic analysis, the interviews were subsequently grouped together into seventeeninitial themes. These themes were then grouped into seven major aspects that described howthe participants perceived resilience underpinned their work. These ‘‘seven aspects of formingresilience’’ contributed to an initial understanding of how paediatric oncology nurses develop

resilience in the face of their personal and professional challenges.

Several key strategies derived from the findings, such as improved rostering, support to anurse’s friend and family, and a clinical support nursing role, could be implemented at anorganizational level to support resilience development within the paediatric oncology setting.

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© 2013 Australian College o

Background

It is widely acknowledged by both health care profes-

sionals and laypersons alike that oncology nursing, and inparticular paediatric oncology nursing, can be personallyand professionally demanding (Ekedahl & Wengström,

∗ Corresponding author at: School of Nursing and Midwifery,Flinders University, GPO Box 2100, Adelaide, SA 5001, Australia.

E-mail addresses: zand0014@flinders.edu.au (M. Zander),alison.hutton@flinders.edu.au (A. Hutton),lindy.king@flinders.edu.au (L. King).

Ptmdmr(F&A

1322-7696/$ — see front matter. © 2013 Australian College of Nursing Ltd. Published by Elsevier Ltd.

doi:10.1016/j.colegn.2012.02.002

rsing Ltd. Published by Elsevier Ltd.

006; Hinds et al., 1998; Isikahn, Comez, & Zafer Danis,004; Lewis, 1999; Muscatello et al., 2006; Papadatou,nagnostopoulous, & Monos, 1994; Papadatou, Bellali,apazoglou, & Petraki, 2002). Stressors that are unique tohis may include but are not limited to grief, loss, bereave-ent, moral and ethical dilemmas regarding treatmentecisions, the influence of clinical trials, complex treat-ent regimens, and managing professional boundaries in

egards to relationships with patients and their families

Bond, 1994; Cohen, Haberman, Steeves, & Deatrick, 1994;lorio, Donnelly, & Zevor, 1998; Hinds, Quargnenti, Hickey,

Magnum, 1994; Isikahn et al., 2004; Kushnir, Rabgin, &zulai, 1997; Lewis, 1999; Muscatello et al., 2006; Olson

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t al., 1998; Solomon et al., 2005; Sparks, 1988). Potentialonsequences of continual exposure to stress in this profes-ional setting include the development of conditions such asurnout, compassion fatigue and vicarious traumatizationLewis, 1999; Maslach, Schaufeli, & Leiter, 2001; Muscatellot al., 2006; Papadatou et al., 1994; Sinclair & Hamill, 2006).here are, however, a myriad of individual and collaborativeactors that are known to mediate stress in the oncology set-ing (Cunningham, 2003; Florio et al., 1998; Maslach et al.,001; Papadatou et al., 1994; Sherman, Edwards, Simonton,

Mehta, 2006). One of these factors, resilience, has beenuggested as an important coping strategy (Ablett & Jones,007).

Resilience can be considered as a physiological or psy-hological concept (Tusaie & Dyer, 2004). Resilience hasreviously been described as the ability to overcome neg-tive situations, or the ‘effective coping and adaptationwhen] faced with loss, hardship or adversity’ (Tugade &redrickson, 2004, p. 320). For the purposes of this studyeport, resilience will be considered as a psychological con-ept. Masten (2001) asserts that everyone has the abilityo develop resilience. Masten states that this developmentf resilience especially results where circumstances jeopar-ize personal growth. According to McGee (2006), resiliences not only seen as an optimistic view on life, but also thebility to undergo personal change enabling the person tohrive and survive the negative experience.

A review of current literature suggests that the presencef resilience among paediatric oncology nurses is possi-le (Zander, Hutton, & King, 2010). Zander, Hutton anding reviewed twenty-four articles relating to coping andesilience of nursing staff in settings where clients wereormally cared for by paediatric oncology trained staff.owever, from the themes identified within the reviewedtudies, it was notable that there is very little researchpecifically into the concept of resilience among paediatricncology nurses, whereas previous studies have exploredesilience among theatre nurses (Gillespie, Chaboyer, Wallis,

Grimbeek, 2007) and inexperienced nurses (Hodges,eeley, & Troyan, 2008), It is not known whether there is

link between resilience and the ability to cope with thetressors of paediatric oncology nursing. Thus the purposef this research was to explore paediatric oncology nurses’erceptions of their development of resilience and how itnderpinned their ability to deal with work-related stress-rs.

im and objectives of the study

he aim of this study was to explore the concept of resiliencemong paediatric oncology nurses who work at the bed-ide, and the process these nurses underwent in order toevelop resilience. In order to explore the development ofesilience in this population, this study had the followingbjectives: (a) to explore the concept of resilience specifico paediatric oncology nurses, (b) to understand the processhat these nurses underwent in order to develop resilience;

c) to determine how resilience underpinned the work of

group of paediatric oncology nurses with varying levels ofxperience involved in the clinical care of children with can-er; and (d) to use the findings to develop strategies that

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an be implemented at an organizational level to supporthe development of resilience in nurses.

esearch design

n order to achieve these objectives, a qualitative case studyas undertaken. Using a naturalistic, qualitative approachas appropriate for this study, as the aim of this researchas to explore and understand the concept of resilience asxperienced by paediatric oncology nurses. It was not theim of the research to quantify the amount of resilienceresent. Rather, the goal was to gain a meaningful under-tanding of the elements involved in the developmentf resilience as experienced by the participants of thistudy.

Whilst the focus of this study lent itself to the potentialse of one of several qualitative traditions or methodolo-ies, case study was chosen. Case study is an approachr method that helps encapsulate in-depth investigationf experience within the multiplicity of the social milieueing studied (Hentz, 2007; Stake, 1995; Taylor, Kermode, &oberts, 2007; Yin, 2003). It was envisaged that if resilienceere present among the study participants, the process ofeveloping this resilience would be described holisticallyhrough case study. Physical, social and environmental ele-ents were sought within the real-world context from which

esilience in nurses emanated.The setting of this study was an eight-bed inpatient

nit with an adjoining outpatient clinical paediatric hema-ology/oncology unit of a tertiary metropolitan paediatricospital in Australia. The inclusion criteria for participantsf this study were:

A registered nurse working within this clinical unit. Involved in the day-to-day care of children with cancer. Having greater than 12 months post-registration nursing

experience.

The reason for exclusion of graduates or nurses in theirrst year of registration was due to the evidence thatuggested the coping processes of these nurses were sig-ificantly different to registered nurses who have had 12onths or more experience (Hinds et al., 1994). Staffembers who were identified as potential participantsere anonymously sent an information sheet regarding the

tudy. Of the twenty nurses who were invited to partic-pate, five participants volunteered to take part in thistudy.

After obtaining informed and written consent, the fiveaediatric oncology nurses were interviewed about theirefinition, perception and understanding of the conceptf resilience, their preferred coping strategies and mech-nisms, and their day-to-day work in paediatric oncology.he interviews were semi-structured in nature, lasting noore than one hour, and were undertaken in office locations

elected by the participants. Each interview was audio-aped and transcribed verbatim. In order to validate the

ontent of each interview, the transcript was sent to thearticipant for verification and further amendment beforet was analysed. Participants were free to withdraw fromhe study at any time, and data supplied by any withdrawn

Exploring Resilience in Paediatric Oncology Nursing 19

Table 1 The data analysis process.

Rose and Webb (1998) step Braun and Clarke (2006) phase Action

Step 1 — Being present at the interview Phase 1 — Familiarising yourselfwith your data

• Conducted interviews and transcribed them

Step 2 — Listening to the tape • Read transcripts in entiretyStep 3 — Transcribing • Reflected on transcripts with regard to study

aimsStep 4 — Reading the transcriptionStep 5 — Repeating steps 1 and 2 to

ensure familiarityStep 6 — Thinking/assimilating/intuiting Phase 2 — Generating initial codes • Examined data for concepts, elements and

aspects that contributed to the study aims• Coded portions of verbatim

Phase 3 — Searching for themes • Read codes• Looked for similarities of concept withincodes• Grouped codes together into themes• Gave initial themes loose definition

Phase 4 — Reviewing themes • Compared and contrasted initial themes forsimilarities• Reflected upon themes against study aims• Compared themes with transcripts, lookingfor the participants’ voices to describe initialthemes• Sought feedback from participants• Re-grouped initial themes into major aspects• Put pertinent quotes together with aspects

Step 7 — Interpretation andunderstanding

Phase 5 — Defining and namingthemes

• Used aspects to provide narrative in order toanswer study aims• Described the major aspects• Selected the most significant quotes

Phase 6 — Producing the report • Wrote findings

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participants would be retracted and not included in the dataanalysis of the study. Ethics approval was sought and grantedfrom both the university Social and Behavioural ResearchEthics Committee and the health service Human ResearchEthics Committee.

Initially it was the author’s intent to triangulate the inter-view data with data from a proposed focus group and aseparate journaling task. However, none of the participantsconsented to keeping a journal throughout the study period,thus removing this potential data source. Secondly, the focusgroup did not go ahead as intended, due to the inabilityto arrange a mutually convenient time with all five partici-pants.

Data analysis

Analysis of the data was adapted from the reflexive approachdescribed by Rose and Webb (1998) and thematic analy-sis from Braun and Clarke (2006). This process was based

on a variation of thematic analysis, an appropriate methodfor the presentation of a case study (De Vaus, 2001). Braunand Clarke (2006) suggest the choice of approach for dataanalysis should be malleable, but not so much that it risks

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hreatening the rigor of the study. The inductive analysisethod outlined by Rose and Webb (1998) and Braun andlarke (2006) was rigorous and well prescribed. These pro-esses were also flexible enough to hear the voice of thearticipants and allow them to drive the findings (Braun

Clarke, 2006), which was at the very heart of this casetudy. These methods were chosen for their flexibility,hich allowed for rich descriptions of the development of

esilience among paediatric oncology nurses, thus improv-ng credibility and fittingness, contributing to the rigor ofhe study. The steps undertaken in the data analysis processan be found in Table 1.

Following transcription of the interviews, the interviewsere read in their entirety. Each interview was then exam-

ned closely for codes, using inductive analysis in order tollow the participants’ data to drive the findings (Braun &larke, 2006). Since Braun and Clarke (2006) define a themes a significant element found within the data that related tohe research aims and questions, portions of verbatim inter-iew were coded only if the aspect described contributed to

he aims of the study.

The initial coding process resulted in 2500 codes in total.hese codes were then examined for similarities in con-ept and grouped together into 17 loosely defined themes.

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he initial 17 themes were then sent to the participants foromment, as well as some initial models originally intendedor focus group discussion showing how the themes could fitogether to describe the process of developing resilience.fter receiving feedback from one of the participants andurther reflection, the initial themes were re-grouped withertinent quotes into the ‘seven major aspects of formingesilience’ that provided answers to the study aims.

indings

he pseudonyms of the five female participants were Kirsty,am, Tracey, Erin and Lauren. This group of nurses haveetween five and twenty-two years of nursing experi-nce, two and a half to sixteen years of working in theaediatric oncology setting within that period. Mostelieved they would not have thought themselves asesilient in the past, but currently believed they hadesilience — Sam believed she was resilient to a degree andrin saw herself as a very resilient person.

The findings of this study were refined into ‘seven majorspects of forming resilience’. These seven aspects clearlyescribed the participants’ perception of resilience andow this resilience underpinned their work. They are thendividual conceptualization of resilience, the issues andhallenges faced by the nurses, actions and strategies, theeed for support, insight, processing situations througheflection and personal and professional experience.

he individual conceptualization of resilience

he participants firstly described their understanding ofhat resilience meant to them. All participants saw

esilience as a personal, multifaceted concept. By exploringheir own personal understanding of resilience, each nurseegan to define their own concept of resilience over time,ithin the context of working and coping in the paediatricncology unit.

Although each participant’s concept of resilience hadheir individual variations, the participants had similar per-eptions of resilience in their working environment. Forome participants, resilience was seen something that coulde learned, whereas for others, resilience was felt to comeaturally to some nurses, as part of their personality. How-ver, they all saw resilience as a life-long skill that coulde developed over time and with experience, inclusive ofersonal and professional growth:

. . .the biggest thing in building resilience is learning fromyour past experiences whether they’re right or wrong,and what your actions have done whether they werepositive or negative (Tracey).

Resilience didn’t mean you forget a situation ever hap-ened, but don’t dwell in it (Kirsty), because for thearticipants, resilience was about using experience to trans-orm issues. Using past experiences to build resilience wasntegral, regardless of whether the experiences were posi-

ive or negative.

. . . even if it might seem something silly, okay, it’s noth-ing compared to what these people go through, but to e

M. Zander et al.

me, that was really s***ty, so I let myself feel that andthen move on (Kirsty).

Regardless of the effort required, once participantsere able to understand the concept and determine itssefulness, these nurses found the willingness to developesilience as well as the strength and vitality to maintain itsevelopment. Having the willingness, strength and vitalityas significant in regard to the development of resilience.ore importantly, the nurses needed to have a conceptu-lization of resilience that was meaningful to them and inarticular, the issues and challenges faced on a daily basis.

he issues and challenges faced

ccording to the participants, resilience would not exist if itere not for the issues and challenges they face, both withinnd outside of their jobs as paediatric oncology nurses.he nurses’ resilience was developed and influenced by the

ssues and challenges faced in both their personal and pro-essional lives over time such that it was meaningful to themersonally. It was seen that:

. . .by facing problems and dealing with problems, youbecome resilient because you don’t give up and go ‘I justcan’t deal with that’ (Sam)

and it was:

. . .very good to have. . . [a] realistic sort of view on whatis possible and what’s not possible (Erin).

By tackling the issues the participants faced rather thangnoring them, these nurses were able to gain a realisticiew of what they were capable of dealing with.

There were a collective group of issues raised by thearticipants that all felt were specific to paediatric oncol-gy nursing, and specifically contributed towards the needor resilience in staff working in this specialty. These issuesncluded:

Being involved in the care of a child dying from cancer. Working with the patients’ families. Ethical issues arising from cancer treatment or palliative

care decisions. Performing invasive procedures on children. Witnessing patient deterioration, treatment failure and

relapse of disease.

The nurses also discussed other nursing specific stressorsnd challenges, including shiftwork, rosters, staffing, skillix, politics within the workplace, career development, andaintaining professionalism. However, the participants felt

he above issues were of more particular concern, as theajority of participants felt there is little to no educationalreparation for the area of paediatric oncology:

. . .it can be very daunting for them because you don’t getmuch pediatric training when you’re studying, you don’tdo much hematology and oncology. . .So you pretty much

have to learn on the job (Tracey).

The issues faced by the nurses also ranged from thosexperienced within the self as well as those arising from the

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Exploring Resilience in Paediatric Oncology Nursing

nurses outside world. In particular, issues arising from workmay impact on the paediatric oncology nurse’s home life:

I once had the flu and I had a fever and I just couldn’tstop thinking about all the kids and what they have to gothrough. . . I think I was reflecting on it too much (Sam).

However personal issues also have the potential to impacton the nurse’s ability to deal with the workplace.

If you’re having troubles in your relationship. . . then thatcan impact your work too. I’ve had that . . . broken upjust before I’ve had to go in for a late shift and. . . yourheadspace is everywhere (Tracey).

The participants agreed the perception of the issuegreatly mediated how stressful the impact of the challengewas on the paediatric oncology nurse. Just as it was distress-ing for Tracey to have to cope with working a shift under theemotional burden of having separated from a partner, it wasalso just as difficult for Sam to detach herself from a nega-tive work situation so that she could enjoy her private life.Thus, this variety of challenges required the nurse to have adiverse range of actions and strategies in order to face themand remain resilient.

Actions and strategies

In order to deal with these issues and challenges, the nursesin this study took action using different strategies and tech-niques to develop resilience, depending on the context ofthe situation. An important point regarding the strategiesused was that:

. . .[people] need to have something in place that worksfor them, because it’s different for everybody (Kirsty).

Strategies ranged from looking after oneself, indul-gences, personal rituals, emotional management andexpression, talking, and problem solving.

Sometimes strategies were as simple as wanting to sit orstand in the shower (Tracey) or going:

. . .home and I’ll vacuum the house and for me, I just feelall my stress just leaving my body and I’m happy and it’sjust. . . one of those things that helps me cope. And a lotof people have different routines and things that theydo and for me, they’re the sort of things that I love todo (Erin).

The participants recognized that different strategieswould work better for some nurses rather than others. Byusing a diverse range of strategies that were as individualas the nurses in this study, it was clear that each nursehad something that worked for them, which helped themto enhance their own resilience.

The need for support

In order to face situations, the nurses realized they needed

to acknowledge the need for support as well as being awareof what support was available to them. It was important thatthe nurses found effective support, particularly if the nursesneeded to talk.

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. . .you might be talking to somebody . . . they’re lookingat you and you don’t think they actually are listeningto you, or they’re just being polite, and sometimes thatcan be a bit hard and you kinda go, ‘‘oh well, there’s notreally much point!’’ (Tracey)

As Tracey identified, sometimes family and friends wereot the most appropriate support. Sam agrees, stating:

I remember being told when I first started working thereyou can’t talk about this [work] to people you. . . are inrelationships with, or your family and [friends] becauseit depresses them. . . it can be a little bit complex . . . forother people to listen to.

However, as Lauren noted, whilst you need your socialife outside of work to kind of forget about work, supportan also come from colleagues, the team or the organiza-ion.

Choose a person who you trust, at work especially, whoyou can talk to about things . . .and it doesn’t mean youhave to talk to everybody, but if it can just be one keyperson who . . . you can grab when you’re feeling a littlebit unsure . . . I think that that’s really important, andthat’s what’s helped me (Kirsty).

With regard to support needs, it was also important toecognize:

. . .everyone’s different. . . some people want to do ittheir own way, other’s prefer. . . a team effort to helpthem be able to bounce off their feelings (Erin).

In order to be resilient the nurses discussed needingffective support from a range of sources. The participantshus recognized that this support could be sourced from per-onal relationships including friends and family, colleagues,he treating team and institutions. What was important washat the nurse determined which source of support wasffective for them.

nsight

n dealing with situations and using support, these nurseseveloped and recognized the need for insight. Participantsefined insight as a clear perception of themselves and theirircumstances. This insight helped them to know and man-ge themselves, as well as accept and acknowledge lessonsnd facts relating to working in paediatric oncology and lifen general. Kirsty particularly felt:

. . .people who have good insight into their own personal-ity and behavior. . .will last longer in this job that peoplewithout insight.

Insight helped the nurses to accept the way things areSam) and be aware of what you can and can’t do (Tracey)nd therefore recognize their individual needs, leading toreater personal resilience.

However working in paediatric oncology also gave nurses

nsight into the realities of life in general:

. . .life is short, life is unpredictable, you really need toappreciate what you’ve got everyday (Erin).

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The specialty itself impacts on how the nurse has growns a professional:

. . .unfortunately that’s the course that some kids dodie. . . that’s where I’ve changed a lot where I think it’snot about myself so much, I really think. . . before it wasabout myself more (Lauren).

This insight, in addition to the paediatric oncology envi-onment, assisted the nurses to develop resilience through:

. . .[recognizing] the fact that they still don’t know every-thing and they’re not perfect and they still have theirown faults (Tracey).

Just as the nurses discussed how resilience builds withime, they also acknowledged how their insight developedith time. The nurses learnt more about themselves over

he years, for example:

. . .being in your early twenties, you think you know your-self really well but you actually don’t, and you don’trealise that til you get a bit older (Kirsty).

The nurses in this study emphasized that insight played aarge role in the development of resilience in the paediatricncology setting. Insight contributed to resilience devel-pment due to improved self-esteem, self-awareness andhe greater development of meaning in the nurse’s personalnd professional life. The participants also saw the abilityo develop insight was heavily influenced by the ability torocess situations through reflection.

rocessing situations through reflection

nsight assisted the nurses to process situations througheflection by thinking, learning and reflecting over time.t was the willingness to reflect on their actions that con-ributed to resilience development:

. . .you find yourself asking a lot of questions to yourself,so I think that helps you reflect on it and look back, seewhat you can actually improve on (Erin).

The questions the participants used include:

. . .looking back going ‘‘Hey, did that actually work?’’ or‘‘I really crashed and burned there, what can I do nexttime to avoid that? (Tracey)

These questions were effective in building resilienceecause it led to:

. . .learning from the experiences . . . learning about whatyour triggers are. . . and how you can maybe approachsituations differently next time, so . . . you can look afteryourself a little bit better (Kirsty).

Sam provided an example of this learning from expe-ience by reflecting upon how she felt about working inaediatric oncology after facing its initial challenges:

I could have gone ‘‘No, I don’t want to work here, it istoo hard and it’s not happening for me’’ but. . . I’m happythat I stuck at it and I really love it now. . . because I gotthrough the hard times.

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M. Zander et al.

Through reflection, one participant realized that hereaction to the stressors she faced began to change:

. . . [when] you first started in the area you reactdifferently. . . over the years you’ve learnt to react inanother way. . . I think that’s made you more resilient,just because you . . . think, ‘‘I’ve seen this before, howdid I react last time’’. . . you reflect back I guess it’s allabout reflection (Lauren).

By taking time out to think and process the situationshey faced, the participants in this study found they wereble to learn from their experiences. Learning occurred byeflecting on the experiences and analyzing the facts of theituations they faced on a daily basis. They also thought andeflected on their interactions with other people, such asatients, families, colleagues and friends. These interac-ions led to the nurses learning lessons from others whilstbout working in paediatric oncology.

ersonal and professional experience

ith insight and reflection, personal and professional expe-ience was gained and built upon in the development ofesilience. For Erin:

. . . life experience has a big, big influence [on resilience]

. . . as you learn to cope with situations and . . . the moreexperience you have . . . you learn to cope better.

Kirsty agreed, recognizing that she had developedesilience through personal and professional experience:

I think it’s just through experience and learning moreabout yourself. . . yeah I think differently - acknowledgehow you feel, learn from the experience and move on.

However Tracey believed age was not a factor in buildingxperience or resilience:

. . . some people go, ‘‘oh the older ones, the mature entrypeople tend to cope better than the younger ones’’.Hmm, not necessarily the case, to be honest sometimesthe younger ones can relate better, so they tend to com-municate a bit better so they can cope a bit better andsometimes the older ones are better.

Thus, participants perceived the influence of age andxperience on resilience in different ways.

For example, often it was a specific experience that trig-ered the nurse into changing her approach:

Maybe you know it was just experience. . . you have afew deaths and think, oh no, you can’t go on like this(Lauren).

The opportunity to reflect on experience provided theurses with the opportunity to recognize what they hadearned from others, what they had learned from theirxternal environment and what they had learned abouthemselves. Reflective practice in that manner may give

hem a better understanding of how they gained their per-onal and professional experience. Regardless of whetherhe experience was personal or professional, past orresent, the important factor, according to the participants

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Exploring Resilience in Paediatric Oncology Nursing

in this study, was that nurses learnt from their experiencesin order to develop resilience.

Discussion

These findings can be situated in the context of current nurs-ing research. Firstly the participants’ definition of resiliencewas consistent with the definitions described in previousliterature; the ability to overcome negative situations, orthe ‘effective coping and adaptation [when] faced withloss, hardship or adversity’ (Tugade & Fredrickson, 2004,p. 320). This consistency thereby provided evidence ofresilience among these particular five paediatric oncologynurses. Furthermore, in discussing typical work situations,the participants provided evidence of resilience under-pinning their work. The seven major aspects of formingresilience were also similar to themes presented by Edward(2005), who investigated resilience among mental health cli-nicians. Edward’s themes included ‘Sense of Self, Faith andHope, Having Insight and Looking after Yourself’ (p. 147).

Whilst the issues and challenges these participants facedcontributed to their experience, the attitudes held towardsthese obstacles were equally important and consistent withprevious findings (Cohen et al., 1994; Cohen & Sarter,1992). It was confirmed by participants that a positive atti-tude was a significant contributor towards resilience. Whatwas unique to this study was the participants consideredresilience in a holistic manner, due to the impact of personalchallenges on work and vice versa. They identified that arange of actions and strategies were required for resilience.Specifically the nurses noted that good health and energywere necessary to be resilient in the paediatric oncologysetting.

In this study it was clear that actions and strategies werechosen by the nurses for one of two reasons: (1) the mecha-nism tackled the issue at hand directly, or (2) the mechanismassisted the nurse to maintain their wellbeing so they couldremain resilient. Therefore in order to develop resilience,these nurses needed access to a range of resources, as wellas the insight to distinguish what strategy was appropriatefor the situation at hand.

In current literature, the need for collegial support hasbeen highlighted in regard to resilience (Maytum, Heiman,& Garwick, 2004). Friends and family have been acknowl-edged as a major support for nurses (Ekedahl & Wengström,2006). The participants in this study provide evidence ofthe importance of this group. In order to develop resilience,effective support is required, however the efficacy ofsupport from friends and family has not been formallyevaluated. Meanwhile, regardless of paediatric oncologyexperience, participants indicated clinical and collegial sup-port was vital. Some participants believed more could bedone, since appropriate skill mix was occasionally a problemfor the unit. Nursing literature may provide some solutionsto improve both clinical and organizational support thatcould contribute to resilience development.

Previously there has been a lack of clarity between the

concepts of resilience and hardiness, two concepts that havebeen linked in literature and often used interchangeably(Zander et al., 2010). It is possible that traits of hardinessas described by Kobasa (1982) may contribute to the nurse’s

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bility to be resilient, It is noted that Kobasa’s work on har-iness was contained within the Connor-Davidson Resiliencecale, a quantitative measure of resilience (Gillespie et al.,007, p. 430). Whilst hardiness involved having commit-ent, a sense of control, and a positive attitude towards

hallenges (Kobasa, 1982, p. 6), hardiness was also defineds the ability to face circumstances stoically (Earvolino-amirez, 2007). Whilst there are a number of definitionsf hardiness that exist within the literature, it was not thentention of this study to explore hardiness. However, thistudy casts doubt as to whether resilience and hardinessan be considered interchangeable concepts from the aboveefinitions. Whilst the participants explained there was aeed for perseverance, resilience was not about stoicism.f a nurse was only stoic they would not, as Kirsty states:pproach situations differently next time. Clearly the par-icipants in this study showed more than stoicism. They wereontinually learning and reflecting on personal and profes-ional experiences. They were developing greater personalnsight to better know themselves. They were able to usehis knowledge to judge what they were capable of andhus adapt to new situations resiliently. Therefore, there is

need to clarify and explore both resilience and hardinesss individual concepts in future research.

uggested strategies to promote resilienceevelopment among paediatric oncologyurses

n order to fulfill the final objective of this study, thendings were used to suggest strategies that could be imple-ented at an organizational level to promote resilienceevelopment in the paediatric oncology setting. It waspparent from the findings that strategies which encouraged

development of a range of coping resources, improved orrovided support, enhanced insight and encouraged reflec-ive practice would assist in increasing experience andherefore resilience development.

Based on issues identified by the participants, a numberf strategies emerge from the study, including the following:

Coping with shift work influenced how physically and emo-tionally prepared the nurses were for the challenges facedat the bedside. Thus a flexible and equitable rosteringsystem may assist nurses to improve their health and well-being, maintain strength and vitality, and mediate theeffects fatigue may have on decreasing resilience.

All participants discussed their initial experiences as newstaff members as an extremely stressful time profession-ally and a time where they felt particularly vulnerable.Therefore there is a need for the provision of a struc-tured orientation program. This program could focus onsupporting newer nurses to develop a range of resourcesto improve the preparedness of those unfamiliar with pae-diatric oncology as a setting.Likewise, there is also a need for the provision of greater

support to the experienced staff members responsible formentoring novice paediatric oncology nurses. This sup-port may be provided by a clinical support nurse (see thefollowing strategy) in the form of clinical supervision.

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To provide greater structure to the collegial support dis-cussed among the participants, the implementation of aclinical support nurse per shift in addition to the shiftcoordinator could be considered. The role of this clinicalsupport nurse may be to provide clinical supervision, asdocumented in other specialties and countries, such asmental health nursing, or as offered by the NHS in theUnited Kingdom (Davey, Desousa, Robinson, & Murrells,2006). Chang, Kicis, and Sangha (2007) suggest that thisis a feasible strategy that may assist nurses regardless ofexperience to better manage shift-related stressors. Theclinical support role may also encourage the developmentof insight and use of reflective practice through activeclinical debriefing.A difficulty the participants often faced were theresponses of friends and family to their professional expe-riences. The offer of support to the nurses’ friends andfamily in addition to collegial support would therebyrecognize the significant contribution these friends andfamily have on the nurses’ resilience. Education sessionsor a hotline similar to the Bush Crisis Line provided torural and remote area nurses and their families by theCouncil of Remote Area Nurses of Australia (2009) may bean effective approach.As one of the major themes was processing through reflec-tion, more opportunity in terms of time and resources toundertake reflective practice may further assist resiliencedevelopment.

imitations of the study

here were several limitations of this study. This study wasmall in nature, as the sample size was limited due to having

small population to draw from. Comparatively, Australianaediatric oncology units tend to be smaller than othernternational centres due to Australia’s relatively small pop-lation of children and adolescents. Whilst it could bergued that the small sample was a limitation of this study,t was not the aim of this case study to quantify the data.

The transcripts were verified with each participant, how-ver there was limited participant feedback regarding thenal seven aspects of forming resilience that constitutedhe findings of the study. This limitation was the result ofhe focus group not going ahead as intended.

There may also be different issues and challenges facedy other units interstate or around the world that may havearticular influence on nursing staff, thus the perception,nderstanding and development of resilience among suchurses may differ accordingly.

mplications for nursing practice, research andducation

his study has particular implications for nursing practice,esearch and education. Firstly this research has uncov-red that paediatric oncology nurses can develop resiliencen the context of their work environment. Regardless of

he level of nursing experience, these nurses develop andaintain resilience over time, but require effective support

rom numerous sources in order to do so. It is imperativehat organizations recognize this development of resilience

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mong their staff and institute initiatives in order to supporturses to both further develop and maintain personal androfessional resilience. Whilst reflective practice has beensed for educative purposes, its application as an effec-ive coping tool needs to be investigated. It is not knowno what extent the support of family and friends mediatesccupational stress, nor the impact of personal issues. Thenfluence of friends, family and personal issues on occupa-ional stress needs to be further investigated to improveupport for nurses in practice. In displaying resilience, thections of the participants highlighted that there is a dis-arity between the concepts of resilience and hardiness.dditional work needs to be carried out to clarify theefinition of these concepts to avoid further confusionithin the literature. Similarly the concept of insight has noteen thoroughly investigated. Future research could definehe concept of insight with regard to nursing practice andts practical applications as both a tool for patient care andoping mechanism for nurses. With an increased understand-ng of how nurses cope with workplace stressors, nursingducators can better prepare nursing students for clinicalracticum and future employment. This may be especiallyrue in paediatric oncology settings, since Hinds et al. (1994)ssert that graduates who had a wider range of copingtrategies were less likely to resign within their first twelveonths of working in a paediatric oncology setting. Thus the

easibility of implementing topics that expose students to range of different coping mechanisms needs to be estab-ished. Finally, as noted in the limitations of this study, theres scope in further research to undertake larger qualitativend mixed-method studies with larger sample sizes similaro this reported study, as this study is quite limited in scopend setting.

onclusion

o conclude, this qualitative case study aimed to explore theoncept of resilience with paediatric oncology nurses andetermine if it underpinned their work, and if so, exam-ne the process of this resilience development. This studyid find evidence of resilience among a group of paedi-tric oncology nurses, which developed within the contextf their working environment through seven major aspects.hilst the nurses developed this resilience of their own

ccord, it was shown that organisational support was vitalo its further development and maintenance. Thus with areater understanding of this process, strategies were sug-ested that could be implemented to enhance resilienceevelopment. The evaluation of the feasibility of theseuggestions and other strategies is a high priority if the pae-iatric oncology specialty wishes to improve recruitmentnd retention rates. Ultimately it is hoped these strategiesill also improve the retention of quality and experienced

taff, thus improving the care of children with cancer nownd into the future.

eferences

blett, J. R., & Jones, R. S. P. (2007). Resilience and well-beingin palliative care staff: A qualitative study of hospice nurses’experience of work. Psycho-Oncology, 16, 733—740.

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Exploring Resilience in Paediatric Oncology Nursing

Bond, D. C. (1994). The measured intensity of work-related stress-ors in pediatric oncology nursing. Journal of Pediatric OncologyNursing, 11, 44—52.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology.Qualitative Research in Psychology, 3, 77—101.

Chang, A., Kicis, J., & Sangha, G. (2007). Effect of the clinical sup-port nurse role on work-related stress for nurses on an inpatientpediatric oncology unit. Journal of Pediatric Oncology Nursing,24, 340—349.

Cohen, M. Z., Haberman, M. R., Steeves, R., & Deatrick, J. A.(1994). Rewards and difficulties of oncology nursing. OncologyNursing Forum, 21(Suppl.), 9—17.

Cohen, M. Z., & Sarter, B. (1992). Love and work: Oncology nurses’view of the meaning of their work. Oncology Nursing Forum, 19,1481—1486.

Council of Remote Area Nurses of Australia. (2009). Bush supportservices — CRANA. Retrieved from http://bcl.crana.org.au/

Cunningham, M. (2003). Impact of trauma work on social work cli-nicians: Empirical findings. Social Work, 48, 451—459.

Davey, B., Desousa, C., Robinson, S., & Murrells, T. (2006). Thepolicy-practice divide: Who has clinical supervision in nursing?Journal of Research in Nursing, 11, 237—248.

De Vaus, D. A. (2001). Research design in social research. London:Sage Publications.

Earvolino-Ramirez, M. (2007). Resilience: A concept analysis. Nurs-ing Forum, 42, 73—82.

Edward, K. (2005). The phenomenon of resilience in crisis caremental health clinicians. International Journal of Mental HealthNursing, 14, 142—148.

Ekedahl, M., & Wengström, Y. (2006). Nurses in cancer care-copingstrategies when encountering existential issues. European Jour-nal of Oncology Nursing, 10, 128—139.

Florio, G. A., Donnelly, J. P., & Zevor, M. A. (1998). The struc-ture of work-related stress and coping among oncology nursesin high-stress medical settings: A transactional analysis. Journalof Occupational Health Psychology, 3, 227—242.

Gillespie, B. M., Chaboyer, W., Wallis, M., & Grimbeek, P. (2007).Resilience in the operating room: Developing and testing of aresilience model. Journal of Advanced Nursing, 59, 427—438.

Hentz, P. B. (2007). Case study: The method. In P. L. Munhall (Ed.),Nursing research — A qualitative perspective (4th edition, pp.349—358). Massachusetts: Jones and Bartlett Publishers.

Hinds, P. S., Quargnenti, A. G., Hickey, S. S., & Magnum, G. H.(1994). A comparison of the stress—response sequence in newand experienced pediatric oncology nurses. Cancer Nursing, 17,61—71.

Hinds, P. S., Sanders, C. B., Srivastava, D. K., Hickey, S., Jayawar-dene, D., Milligan, M., et al. (1998). Testing the stress—responsesequence model in pediatric oncology nursing. Journal ofAdvanced Nursing, 28, 1146—1157.

Hodges, H. F., Keeley, A. C., & Troyan, P. J. (2008). Professionalresilience in baccalaureate-prepared acute care nurses: Firststeps. Nursing Education Perspectives, 29, 80—89.

Isikahn, V., Comez, T., & Zafer Danis, M. (2004). Job stress and cop-ing strategies in health care professionals working with cancerpatients. European Journal of Oncology Nursing, 8, 234—244.

Kobasa, S. C. (1982). The hardy personality: Toward a social psy-chology of stress and health. In G. S. Sanders, & J. Suls (Eds.),Social psychology of health and illness (pp. 3—32). New Jersey:Lawrence Erlbaum Associates, Inc.

Z

25

ushnir, T., Rabgin, S., & Azulai, S. (1997). A descriptive study ofstress management in a group of pediatric oncology nurses. Can-cer Nursing, 20, 414—421.

ewis, A. E. (1999). Reducing burnout: Development of an oncol-ogy staff bereavement program. Oncology Nursing Forum, 26,1065—1069.

aslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout.Annual Review of Psychology, 52, 397—422.

asten, A. S. (2001). Ordinary magic — Resilience processes indevelopment. American Psychologist, 56, 227—238.

aytum, J. C., Heiman, M. B., & Garwick, A. W. (2004). Com-passion fatigue and burnout in nurses who work with childrenwith chronic conditions and their families. Journal of PediatricHealth Care, 18, 171—179.

cGee, E. M. (2006). The healing circle: Resiliency in nurses. Issuesin Mental Health Nursing, 27, 43—57.

uscatello, M. R. A., Bruno, A., Carroccio, C., Cedro, C., La Torre,D., Di Rosa, A. E., et al. (2006). Association between burnoutand anger in oncology versus ophthalmology health care profes-sionals. Psychological Report, 99, 641—650.

lson, M. S., Hinds, P. S., Euell, K., Quargnenti, A., Milligan, M.,Foppiano, P., et al. (1998). Peak and nadir experiences and theirconsequences described by pediatric oncology nurses. Journalof Pediatric Oncology Nursing, 15, 13—24.

apadatou, D., Anagnostopoulous, F., & Monos, D. (1994). Factorscontributing to the development of burnout in oncology nursing.British Journal of Medical Psychology, 67, 187—199.

apadatou, D., Bellali, T., Papazoglou, I., & Petraki, D. (2002).Greek nurse and physician grief as a result of caring for childrendying of cancer. Pediatric Nursing, 28, 345—364.

ose, K., & Webb, C. (1998). Analysing data: Maintainingrigor in a qualitative study. Qualitative Health Research, 8,556—562.

herman, A. C., Edwards, D., Simonton, S., & Mehta, P. (2006).Caregiver stress and burnout in an oncology unit. Palliative andSupportive Care, 4, 65—81.

inclair, H. A. H, & Hamill, C. (2006). Does vicarious traumatisationaffect oncology nurses? A literature review. European Journal ofOncology Nursing, 11, 348—356.

olomon, M. Z., Sellers, D. E., Heller, K. S., Dokken, D. L., Levetown,M., Rushton, C., et al. (2005). New and lingering controversiesin pediatric end-of-life care. Pediatrics, 116, 872—883.

parks, T. F. (1988). Coping with the psychosocial stresses of oncol-ogy care. Journal of Psychosocial Oncology, 6, 165—197.

take, R. E. (1995). The art of case study research. California: SagePublications.

aylor, B., Kermode, S., & Roberts, K. (2007). Research in nursingand health care: Evidence for practice (3rd edition). Melbourne:Thomson.

ugade, M. M., & Fredrickson, B. L. (2004). Resilient individualsuse positive emotions to bounce back from negative emotionalexperiences. Journal of Personality and Social Psychology, 86,320—333.

usaie, K., & Dyer, J. (2004). Resilience: A historical review of theconstruct. Holistic Nursing Practice, 18, 3—8.

in, R. K. (2003). Case study research — Design and methods (3rd

edition). California: Sage Publications.

ander, M., Hutton, A., & King, L. (2010). Coping and resilience fac-tors in nurses working in pediatric oncology. Journal of PediatricOncology Nursing, 27, 94—108.