Mental health nurses' resilience in the context of emotional labour: An interpretive qualitative study.

Strengthening mental health nurses' (MHNs) resilience may help mitigate the negative effects of the emotional labour (EL) of their work. There is no prior evidence on MHNs' experiences of resilience in the context of EL. This interpretive qualitative study sought to explore how MHNs build and maintain their resilience in the face of high levels of EL. Semi-structured interviews were conducted with 11 MHNs. Reflexive thematic analysis was used to analyse the data. Four main themes were constructed. The first three; Being attuned to self and others, Having a positive mindset grounded in purpose, and Maintaining psychological equilibrium through proactive self-care, describe how MHNs build and maintain their resilience. The fourth theme, Running on emotionally empty, describes what impedes MHNs' resilience. MHNs engaged in internal self-regulatory processes to manage their mental and emotional state. They maintained intra- and inter-personal boundaries and proactively used self-care strategies to maintain their well-being. Through this, they were able to replenish and sustain the energy required to maintain a state of equilibrium between themselves, their interpersonal practice, and their working environment, and to positively adapt to EL. However, lack of organizational support and high workplace demands can negatively impact MHNs' equilibrium and adaptive ability. There is a need for organizations to proactively work to reduce workplace stressors, and support MHNs' professional well-being and practice. Education and support strategies focused on strengthening MHNs' resilience, well-being, and mental health practice capabilities, including the provision of clinical supervision, and clear role expectations within MHNs' scope of practice are recommended.

INTRODUCTION

Mental health nurses (MHNs) can often face emotionally challenging situations at work. This may be in the context of bearing witness to consumers' and carers' emotional distress, interpersonal conflict with colleagues, or because of cumulative daily interpersonal challenges in working therapeutically and professionally with others (Foster et al. 2018a, 2020, 2021; Hasan et al. 2018). Organizational stressors and practice demands, such as restrictive practices, time constraints, staff shortages, work overload, and/or negative workplace culture, can further compound relational challenges at work. These stressors can have substantial negative impacts on MHNs' personal well‐being and professional practice. Nurses can experience increasing stress and distressing emotions, and diminished quality of interpersonal work with consumers and carers (Foster et al. 2020, 2021; Hasan et al. 2018).

The relational nature of MHN's work requires them to engage in emotional labour (EL); regulating their emotions, and managing their emotional expression and related behaviour at work to maintain the professional demeanour required to meet others' needs (Delgado et al. 2017, 2020; Edward et al. 2017). The EL of mental health (MH) nursing is recognized as a form of workplace emotional adversity (Delgado et al. 2017, 2020). Strengthening MHNs' workplace resilience may be protective against the negative impacts of EL. There is emerging quantitative evidence suggesting that MHNs have the capacity to build their resilience despite facing emotional adversity at work (Delgado et al. 2020; Foster et al. 2018b, 2020). There is limited qualitative evidence, however, on MHNs' resilience, and no qualitative evidence on resilience in the context of MHNs' EL.

BACKGROUND

Workplace resilience is a dynamic person–environment interactive process of positive adaptation in the face of adversity and change (King & Rothstein 2010; Winwood et al. 2013). This involves engaging in self‐regulatory emotional, cognitive, and behavioural processes, alongside protective personal, interpersonal, and environmental factors. Together, these internal and external factors help build people's capacity to adapt to adversity and promote increased well‐being and performance at work (King & Rothstein 2010; McLarnon & Rothstein 2013).

Resilience research conducted with MHNs is limited in comparison to the broader nursing field (Foster et al. 2019). A review of international literature (Foster et al. 2019) highlighted a few empirical studies that qualitatively explored (n = 4) or quantitatively measured (n = 5) MHNs' resilience. Subsequently, there have been other studies investigating MHNs' resilience (Abram & Jacobowitz 2021; Chang et al. 2019; Delgado et al. 2020, 2021; Doğan & Boyacıoğlu 2021; Foster et al. 2020; Henshall et al. 2020; Sukut et al. 2021). Three of these (Delgado et al. 2020, 2021; Foster et al. 2020) specifically investigated workplace resilience (resilience hereafter). Foster et al. (2020) investigated the association between workplace stressors and MHNs' resilience, psychological well‐being, and caring practices. A key finding was MHNs' well‐being was lower for those who reported consumer‐related stressors as their most challenging form of emotional adversity. Delgado et al.'s (2021) study investigated MHNs' resilience, mental distress, and psychological well‐being. Depression, anxiety, and stress were each negatively associated with resilience and psychological well‐being, while psychological well‐being was positively correlated with resilience. Delgado et al.'s (2020) study is the only quantitative study to date that has specifically investigated MHNs' resilience in the context of their EL. Findings included an inverse relationship between MHNs' resilience and EL, and that MHNs' capacity for positive adaptation was lower for those who reported higher levels of EL. Except for the four qualitative studies (Edward 2005; Foster et al. 2018a; Marie et al. 2017; Prosser et al. 2017) identified in Foster et al.'s (2019) review, there has been no other qualitative exploration of MHNs' experiences of resilience since. To address the gap in knowledge on MHNs' resilience in the face of EL, the aim of this study was to explore how MHNs build and maintain their resilience in the face of high levels of EL. Three questions guided the study: How do MHNs draw on personal strategies and skills to build and maintain their resilience; what other resources do MHNs draw on to build and maintain their resilience; and what might impede MHNs' resilience?

METHODS

This study comprises the sequential qualitative phase of a larger mixed‐methods study on Australian MHNs' workplace resilience and EL (Delgado et al., 2020). This paper reports the qualitative phase findings guided by the Standards for Reporting Qualitative Research (O'Brien et al. 2014). Ethics approval was granted by the relevant University's Human Research Ethics Committee (2017‐246H).

Research design

An interpretive qualitative research design was used to explore and gain an understanding of participants' experiences and meanings of resilience, EL, and how they build their resilience at work from their perspective. This approach underpins research inquiry that seeks to understand people's experiences, perspectives, and the meaning they ascribe to their experience of a phenomenon in their unique context (Merriam & Grenier 2019; Schwartz‐Shea & Yanow 2012). Interpretive designs are suited to explanatory sequential mixed methods research studies in that the in‐depth qualitative data produced by interpretive analysis can provide a deeper understanding of quantitative findings (Creswell et al. 2006). In this study, an interpretive approach was the most relevant to address the study aim and explore participants' experiences; bringing to light their voices and perspectives on resilience and EL.

Participants and setting

Participants were Australian MHNs. They were purposively selected from the initial quantitative phase of the study based on having higher than mean resilience scores as measured by the Resilience at Work measure (Winwood et al. 2013) (M = 70.27 ± SD = 11.53 (69.24–71.31)), and higher than mean scores for the EL aspects of surface acting (M = 8.87 ± SD = 2.05 (8.67–9.01)) and intensity (M = 5.29 ± SD = 1.41 (5.16–5.42)) as measured by the Emotional Labour Scale (Brotheridge & Lee 2003). Eighteen (n = 18) MHNs met the criteria for selection. Eleven (n = 11) responded to follow‐up contact. MHNs provided written and verbal informed consent prior to the interview. All MHNs were given a pseudonym and any identifying details were de‐identified to protect their anonymity and privacy.

Data collection

Individual semi‐structured and audiotaped telephone interviews ranging between 40 and 60 minutes were conducted by the first author between January to June 2019. Telephone interviews allowed flexibility for participants to choose the time that suited them, and were practical in reaching participants spread across wide geographical areas (Roller & Lavrakas 2015). The semi‐structured format allowed MHNs to voice their experiences and lead the conversation. This format also allowed for adaptation and modification of questions and their sequencing in the interview according to responses and explore these in more depth (Holloway 2017; Roulston & Choi 2018). The questions were designed to elicit data related to the research aim, were open‐ended, and used prompts where relevant; for example: What do you understand EL to at work to be? How would you describe your experience of EL at work? What does resilience mean to you in the context of your work? How do you build and maintain your resilience at work? Definitions of resilience and EL were provided to participants as required after they first described their understandings of these phenomena. Field notes were made during and after interviews. Brief demographic data were also collected including age, gender, and years of experience working in MH.

Data analysis

Interviews were transcribed verbatim. Interview and field note textual data were analysed using reflexive thematic analysis (RTA). This method guides the iterative process of identifying, analysing, interpreting, and reporting patterns of meaning or themes within a qualitative data set (Braun et al. 2019; Braun & Clarke 2006, 2021a). RTA is flexible in that it can be situated within a range of qualitative approaches. The main aim of RTA is to interpret data to gain an understanding of patterns of meaning. For these reasons, this analytic approach sits well within an interpretive qualitative design (Braun et al. 2019; Terry & Hayfield 2020).

Using the six phases of RTA (Braun et al. 2019; Braun & Clarke 2006, 2021a), the first author familiarized themselves and engaged with the data by listening to audio recordings, then reading transcripts and field notes multiple times. Transcripts and transcript data were stored, organized, coded, and managed within Nvivo 12 Plus (QSR International 2020). Initial coding involved selecting and labelling text segments reflective of words or sentences that related to the study aim and questions. Codes were then collated into groups, each reflecting a pattern of meaning. Initial themes were generated through an iterative process of revising individual sets of data and how they linked together as a whole. To support reflexivity and rigour, ongoing in‐depth analysis and repeated revision and discussion of themes were conducted by all authors. Through this process, themes continued to be refined and defined until they reflected what was meaningful about the data and the central organizing concept was apparent. The final revision of themes involved ensuring that these addressed the study aim. The themes are reported and illustrated using selected data extracts (Braun et al. 2019; Braun & Clarke 2006, 2021a,b; Saldaña 2015). An adapted version of Foster and McCloughen's (2020) Cognitive, Emotional, Relational, and Behavioural (CERB) framework was used as an organizing heuristic for coding self‐care strategies (Theme 3).

FINDINGS

Demographic characteristics are in Table 1. Inpatient and community MH settings were evenly represented in this study; half of the participants worked in either or both settings. Irrespective of the setting, with respect to EL, all MHNs had experienced highly charged emotional situations working with consumers, carers, or colleagues who expressed high levels of emotional stress and/or distress. Often, this involved MHNs being threatened, verbally and/or physically abused, and/or witnessing self‐harming or aggressive behaviour. Sometimes, highly charge emotional situations were  related to experiencing other confronting situations such as witnessing or participating in the restraint of consumers, bearing witness to traumatic accounts, or collegial conflict. Additionally, all MHNs in this study engaged in EL because of challenging organizational situations and demands. This was predominantly attributed to staff shortages, increased workloads – often related to documentation, reporting, or other administrative tasks, and more generally, a lack of resources and support. For MHNs working in community settings, having a large ‘caseload’, and feeling continually pressured to take on more, was another workplace stressor that required them to engage in EL. To deal with the emotional demands of these situations, MHNs engaged in an overarching regulatory process of continually managing themselves mentally and emotionally, to regain their mental and emotional equilibrium. This involved drawing on personal skills and self‐care strategies, supports, and resources to recover and sustain the energy required to maintain intrapersonal, interpersonal, and external boundaries. This was essential to maintaining their professional interpersonal practice and key to how MHNs built and maintained their capacity for resilience at work. Four themes were generated from the analysis. Three themes related to how MHNs build and maintain their resilience: Being attuned to self and others, Having a positive mindset grounded in purpose, and Maintaining psychological equilibrium through proactive self‐care. The fourth theme – Running on emotionally empty – described factors that may impede MHNs' resilience.

Table 1

Participant characteristics

Descriptor	N
Gender
Female	7
Male	4
Age (range 29–66)
25–34	4
35–44	1
45–54	2
55–64	3
≥65	1
Years of experience working in psychiatry/mental health (range 1–46)
≤10	4
11–20	3
21–30	1
31–40	2
≥41	1
Workplace setting
Inpatient	5
Community	5
Across inpatient and community	1
Specialist postgraduate mental health nursing qualification
Yes	3
No	8
Receives clinical supervision
Yes	8
No	3

Being attuned to self and others

During emotionally challenging situations, MHNs drew on a range of cognitive and emotional skills to establish and maintain intrapersonal boundaries and stay attuned to themselves and others. In this process, MHNs were self‐aware and connected to themselves and their mental and emotional experiences. At the same time, they used their empathic skills to appreciate another's position. This involved a conscious process of introspection and reflection that helped MHNs appraise their emotional state, thoughts, behaviour, and perception. This allowed them to recognize if/when they were at risk of becoming emotionally overwhelmed and/or emotionally reactive. In consideration of the potential consequences this could have on their interpersonal interactions, MHNs kept this boundary firm. In turn, they continued to respond from a professional rather than a personal position:

…sometimes things aren't going to get solved in that moment and everybody needs a breather, …even when I'm verbally de‐escalating a person, I've learnt that sometimes, not just for that person but also for myself, I need to move away, take a breather, and then go back because it [staying in an interaction when emotionally overwhelmed] becomes unhelpful… [Charlie]

By staying aware and attuned to themselves and others, MHNs were able to manage their feelings and behaviour, and maintain their mental and emotional boundaries. This helped them to recalibrate their focus and reframe their perspective of the person and situation beyond their own emotional experience. By drawing on their insights from prior interpersonal work, and their knowledge of the person and their situational context, they actively sought to understand the reasons behind others' emotional experiences. As a result, they were able to consider the other person's position and realistic possibilities for others' emotional expression during challenging interactions:

I've been called that [derogatory insults] a few times. The natural response is you want to scream at the person …make them feel what they made you feel…, …that takes quite a lot of emotional awareness…, …sometimes the insult is not necessarily targeted at you but what you represent… [Jaime]

Mental health nurses were also attuned to their professional capacity and cognisant of their professional capabilities and limitations in their interpersonal work. This helped them reflect on and reappraise emotionally challenging situations in terms of boundaries around their capacity: what, and the extent to which, they could or could not achieve according to the circumstances at the time. This assisted them to manage themselves and their self‐expectations, and focus on those aspects of their work they could influence:

Resilience is putting things into perspective…, I know sometimes I can't give any answers. You just give the space for someone to talk, we listen, and try and focus on what we can do rather than what we may hope to do, because some things are out of the control of the ‘controllables’… [Steve]

Having a positive mindset grounded in purpose

To maintain their resilience, MHNs held intrapersonal and interpersonal boundaries by connecting to their professional sense of purpose and having a positive mindset. They engaged in a process of reflection about their professional role and responsibilities, what their work meant to them, and how, through using themselves, they could positively contribute to another person's experience. MHNs' sense of purpose seemed connected to altruistic values including compassion, kindness, hope, service, and making a difference, which they believed important for meaningful and effective therapeutic work, and maintaining a positive connection to others. This underpinned MHNs' drive to be the best version of themselves for the purpose of helping others to heal and recover while remaining grounded and maintaining interpersonal boundaries. This was reflected in consciously adopting a professional and therapeutic stance; taking purposeful action towards positive resolution during emotionally charged situations. MHNs' positive mindset and their connection to their sense of purpose were vital in regaining their mental and emotional energy and their resilience:

…if you feel as though you have a sense of purpose and you're actually making a positive change, is probably what brings you the most resilience…to be resilient I look for the positive and the good in situations and remind myself that it's not about me, it's about the person [Don]

Mental health nurses' capacity for tolerating their and/or others' intense and distressing emotions was regularly stretched. However, by staying connected to their purpose and focusing on positive aspects of their work they were able to be emotionally flexible. Within this process, they used emotional regulation strategies, including self‐management and cognitive reappraisal skills, to acknowledge and let go of negative emotions. This allowed them to re‐establish their mental and emotional balance and boundaries, and helped them to make decisions about their professional actions with equanimity and purpose:

To see people live their lives and flourish is why we do what we do, …we should take the time and look at, “we've had three incidents but we've made a massive positive difference to a lot of people that have come in through our doors [Jaime]

Maintaining psychological equilibrium through proactive self‐care

To maintain their resilience MHNs actively engaged in personal and professional self‐care strategies that promoted their mental and emotional equilibrium. They recognized that their health and well‐being were linked to their capacity to self‐manage, think clearly, and be empathic. Therefore, they proactively used a wide range of resources that promoted a good work–life balance and kept both body and mind healthy. They considered this essential for maintaining mental–emotional fitness and equilibrium for therapeutic work, and required them to employ a range of CERB strategies (See Table 2).

Table 2

CERB framework of self‐care strategies for building and maintaining well‐being and resilience

Personal strategies
Cognitive †	Description
Engage in activities that help clear and slow down the mind	Consistently attending and engaging in either physical exercise (e.g., going for walks; swimming; running; and going to gym) or relaxation‐focused activities (e.g., yoga; meditation; and mindfulness) that help focus, clear the mind, slow down thinking, and/or relax the body and mind
Establish mental boundaries between home and work	Remaining cognisant and reminding self to leave work at work by focusing on personal goals, needs, activities, or tasks liked to be completed at home or in one's broader family/social life
Have intent and goals to maintain a balanced and healthy life	Focusing on maintaining own biopsychosocial health and well‐being. Developing clear health and well‐being goals, inclusive of routines and plans around physical or social activities that promote mental and emotional balance
Turn ‘work head’ on and off	Mentally preparing to start or leave work and/or engaging in activities/rituals before and/or after work to try to separate personal life from work (e.g., using exercise to gather thoughts and clear the mind; using mindfulness techniques to promote a calm state of mind; changing clothes before leaving work; taking work shoes off before entering the home; and mentally acknowledging the end point of working day)
Personal values, beliefs, and mindset arising from life experience will influence resilient behaviours	Recognizing values, beliefs, and patterns in own behaviour, life lessons, internal resources, and ways of communicating which influence how to self‐care, relate to others ‡ , and self‐manage. Having a ‘can‐do’ attitude and positive mindset including the self‐belief of having the ability/capability/capacity to get through and/or bounce back from challenges

The Cognitive, Emotional, Relational, Behavioural (CERB) framework includes self‐care strategies identified by MHNs in the study respectively in their personal and professional life. Although strategies (codes) and their descriptions have been listed under each CERB domain, these can overlap and interact with each other. These can also occur simultaneously. Many of the self‐care strategies used by MHNs in their professional life also apply to their personal life.

Cognitive domain: Personal (internal) mental strategies and resources, and/or activities and external resources that promote and support mental well‐being.

‘Others’ refers to consumers, carers/family, or colleagues.

Emotional domain: Personal (internal) emotional strategies and resources, and/or activities and external resources that promote and support emotional well‐being.

Relational domain: Interpersonal strategies, activities, and resources that promote and support biopsychosocial well‐being.

Behavioural domain: Behaviour and/or action‐based strategies, activities, and resources that promote and support biopsychosocial well‐being.

Cognitive strategies included self‐care activities and resources used to promote and support mental well‐being. At a personal level, these included regular physical exercise, hobbies, and other activities that allowed MHNs to focus on something other than work. This helped MHNs to mentally rest, clear their mind, and replenish mental energy, which helped maintain their boundaries. At work, cognitive self‐care strategies included consciously shifting their attention from tasks, demands, or interpersonal experiences that were mentally draining to those that were less depleting. Strategies also included proactively seeking and engaging with support and resources to advance their professional development and growth. They considered these fundamental to their learning, particularly their intrapersonal capabilities such as self‐awareness, self‐reflection, and cognitive appraisal skills, which help maintain intrapersonal and interpersonal boundaries:

…education and training build your confidence…, reflecting on practice… it wasn't until I started getting [clinical] supervision that made me feel I am becoming more resilient as a clinician. I've also tried to do a few different roles to see things from other ways and I think that's helped me build resilience as well… [Charlie]

Emotional strategies included activities and resources that allowed MHNs to maintain their energy and well‐being, which helped them emotionally regulate and act with awareness rather than react at work. For example, MHNs sought psychological support outside work such as counselling, coaching, or seeing an MH professional when they felt emotionally depleted or experienced prolonged stress and/or ill‐health. Professionally, they proactively sought and engaged with organizational supports such as debriefing, employee assistance programs, or staff well‐being programs when they experienced emotionally charged situations. MHNs also practised daily emotional self‐care by taking regular scheduled or unscheduled breaks to prevent or interrupt high emotional arousal, and to reenergise themselves to deal with their EL:

One thing I make sure I do every day at work to keep me okay, is to make sure I take my breaks…, giving your mind that time to break from what's going on to focus on something that isn't as emotionally draining… [Natalie]

Relational self‐care strategies were used by MHNs to build and maintain their well‐being. This included trusted relationships with family, friends, and colleagues, in order to reenergise and maintain boundaries. The social connection was a thread across every theme and a prominent factor in MHNs' resilience and well‐being. Engaging with others in their personal life, for example, helped MHNs shift their focus from work onto other areas of their life and in doing so, keep a boundary between themselves and work. Professionally, maintaining relationships with trusted colleagues and/or within a cohesive team were considered a key strategy by MHNs to draw strength, seek support, and learn from the collective. This helped them reenergise when they felt depleted and unable to maintain their mental, emotional, and interpersonal boundaries. In feeling validated, supported, and/or inspired by their colleagues, MHNs were able to regain or maintain their equilibrium to address the demands of work:

I always had mentors and people I knew who to go to, and because I was interested in learning, you would always get people keen to help you, like I do now. [Audrey]

Behavioural strategies included action‐based activities and resources that allowed MHNs to replenish their mental and emotional energy. They proactively planned and took longer breaks to rest and reset themselves. On working days, they consistently strived to leave work on time. Boundaries were also reflected in MHNs' ability to say “no” to requests for additional work or spending extra time at work. They renegotiated priorities when faced with multiple demands; taking steps to complete one priority at a time. These strategies were particularly helpful when they recognized their energy was depleted.

Resilience needs you to set fairly firm boundaries… and recognize when you need to look after you. Or you need to step back, say something, or stand up for somebody. I think that's true resilience. It's not the ability just to be enduring, like a soldier. [Bella]

Running on emotionally empty

This final theme describes what impeded MHNs' resilience and well‐being. This was the experience of only some participants at some points in their careers. On these occasions, MHNs were not able to fully employ or sustain the usual strategies, or engage in and access supports and resources, described in the previous three themes. This resulted in their inability to maintain their psychological equilibrium and ‘fitness’. They felt overworked and emotionally overwhelmed, overstretched, and drained. They became ‘unbalanced’ in energy and unable to maintain boundaries to self‐regulate and manage their EL. They were ‘running on emotionally empty’. This was usually in the face of increasing workplace demands combined with a lack of organizational support and resources.

…we're supposed to check our workload, how we're managing, what we do, how much you know, how we're coping with the workload, or not. But that doesn't really work because the amount of work coming through is a lot higher than the capacity that we have as clinicians. [Maureen]

The emotional demands of interpersonal work were compounded at times by feeling pressured to take on additional work due to ongoing staff shortages, being allocated a higher caseload, and trying to meet perceived expectations to complete tasks in the face of poor resourcing and time. During these times, it also appeared that MHNs did not recognize their own state of disequilibrium. They could become tunnel‐visioned, continuing to attend to tasks, fuelled by a stress‐driven desire to complete them. There seemed to be a collective resignation and acceptance about these stressors being an inevitable aspect of their work; normalized by MHNs and their peers through a veiled culture of silence in the workplace. This included at times not feeling supported or encouraged by colleagues or leaders/managers to access resources that could have strengthened their resilience. Even if/when MHNs recognized they felt overwhelmed and depleted, they tended to remain silent about their needs and demands being placed on them. This resulted in feeling helpless and powerless, and futility in raising issues:

…the problem is that people say “Well, there's no point in saying anything, and it's really terrible working here, and I don't want to move because I've got this, and I've got that, so, let's not complain”, and that does not help people… [Rose]

Mental health nurses' lack of psychological equilibrium and energy was at times further compounded when their organizations did not have adequate processes or resources to support their professional self‐care and well‐being. These included clinical supervision not being available or supported, not being supported to attend available education/training, or not being given other professional development and career opportunities such as secondments to work in a different role or area. This also included a seeming lack of recognition by the organization of the impact of the work on MHNs' sense of safety and well‐being. There was a perceived expectation to continue to attend to work ‘as usual’ despite serious and confronting interpersonal situations, and/or in the face of long‐term staff shortages and clinician experience gaps. As a result, MHNs felt undervalued, unappreciated, and unsupported which contributed to their sense of powerlessness and put their well‐being at risk:

…he looked at me and said, “You f'n bitch. I'm gonna have you murdered outside of work…” After that, this consumer was allowed unescorted leave… I contacted my manager just to let them know of the situation. Their advice… to notify them anytime I left the building…, I felt like it was me having to deal, document, do incident reports, contact managers, and when I came to work, I had to think about which door of the building I had to come through in case the consumer was standing outside…for at least three or four days, I was frightened. I did not want to come into work, but I continued to come into work… [Emily]

…we've had a mass exodus of experienced nurses, …if you've got a poor skill mix, you kind of get set up to fail, because things can be challenging and you don't have enough people to back you up, therefore it can make you feel really down about your practice, …it makes you feel like you've failed, but really it's kind of a system failure… [Charlie]

DISCUSSION

This study is the first to explore MHNs' experiences of how they build and maintain their resilience in the face of EL. A key, and new, finding of this study was that MHNs' resilience – the capacity to positively adapt in the face of emotionally challenging situations – was linked to an overarching process of sustaining personal equilibrium. That is, MHNs constantly engaged in internal self‐regulatory processes to manage their mental and emotional state to gain/regain internal balance and well‐being. This required them to draw on internal and external supports and resources to enable them to maintain a state of equilibrium within themselves. In doing so, they were able to adapt their behaviour and/or take actions that allowed them to also maintain equilibrium in their interpersonal practice and with their working environment. Equilibrium was an important factor needed for MHNs to positively adapt to emotional adversity in their work and maintain professionalism.

A key aspect to maintaining internal equilibrium was MHNs' ability to consciously engage in self‐regulation. They had awareness of their mental and emotional states and insight into how these could affect their behaviour. As a result, they were able to reflect on how this could impact their interpersonal work and personal well‐being. Thus, they made choices and took action to alter their internal state and emotional‐behavioural responses if/when their equilibrium was challenged. Of note, self‐regulation inextricably involves emotional regulation, a recognized aspect of emotional intelligence (EI) (Mayer et al. 2004). Emotional regulation has been identified as a key ability for MHNs to effectively conduct their therapeutic interpersonal work, and protect against the negative impacts of EL (Edward et al. 2017; Foster et al. 2018a). Emotional regulation, however, is only one form of self‐regulation, and, although it also involves cognitive reappraisal skills, and this influences behaviour (Gross 2002; Mayer et al. 2004), findings in this study emphasize that in addition to emotional regulation, MHNs' consciously engaged in cognitive‐mental and behavioural self‐regulation. All three were used in conjunction with the other to maintain internal equilibrium. Further, self‐regulation was found to be a significant factor in maintaining well‐being, and for MHNs' ability for ongoing adaptation against the interpersonal demands of their work. This study has shown that self‐regulation is key for MHNs to sustain positive adaptation to adversity in the face of multiple stressors, and in the longer term, beyond singular adverse events. This extends existing knowledge from the general workplace resilience literature (King & Rothstein 2010; McLarnon & Rothstein 2013) that identified self‐regulatory processes, in conjunction with personal and external protective resources, as part of adaptive responses that can lead to the restoration of well‐being and work performance outcomes following single adverse events.

Another finding was that maintaining well‐being was essential in sustaining the mental and emotional energy that MHNs need to continue regulating themselves at work and maintain professionalism. To replenish their energy and maintain their well‐being, MHNs engaged in various personal and professional self‐care strategies (Table 2). This is an expanded range of strategies that extends prior knowledge of self‐care strategies used by MHNs (Delgado et al. 2017; Foster et al. 2019), in that proactive self‐care at work, in addition to personal self‐care, are essential for replenishing the energy required by MHNs to maintain their equilibrium and well‐being. This, however, is not without its challenges. MHNs in this study at times experienced, and more often witnessed colleagues, being emotionally overwhelmed and unable to maintain equilibrium, due to challenging interpersonal experiences or organizational issues, such as increasing workloads in the face of staff shortages and competing demands. In concordance with findings reported in the broader nursing literature (Mills et al. 2018; Ross et al. 2019), in these instances, when needed the most, self‐care at work was low in MHNs' priorities; and/or workplace supports, and resources were not routinely or readily available. This is highly concerning given the potential negative impacts on consumer/carer outcomes when MHNs experience lowered well‐being (Foster et al. 2020, 2021; Hasan et al. 2018). These findings emphasize that promoting MHNs' resilience, inclusive of strategies that support their self‐care and well‐being is a shared responsibility (Foster et al. 2018a). That is, there is a need for organizations to provide relevant and adequate support and resources, but also have processes in place to help MHNs identify self‐care needs and access support and resources when needed. Equally, MHNs have responsibility for their own professional growth, and access and implement strategies that help them maintain their equilibrium and well‐being. Importantly, MHNs in this study proactively and variously used different strategies at different times. They regularly enacted strategies as a preventative measure to promote and maintain their well‐being, and/or, depending on the situation and context, used different strategies to replenish their energy and maintain their equilibrium at the time. Strategies reported here (Table 2) could be used to inform future professional learning and development for MHNs, particularly for those new to MH practice.

This study also found that enacting boundaries was identified as a key strategy and form of professional and personal self‐care. MHNs in the current study regularly engaged in a process of enacting and maintaining boundaries – mentally, emotionally, physically, interpersonally, and between them and their work. With a clear understanding of what their individual professional behaviour and scope of practice were, MHNs used their boundaries to maintain their professionalism during therapeutic and collegial interactions. The MH nursing literature typically refers to boundaries in the context of therapeutic and professional relationships, and more often in relation to crossing or violating boundaries in practice with consumers/carers (Pettman et al. 2019; Valente 2017). However, the concept of boundaries, as applied to MH nursing interpersonal work, is extended in this study, in that we found it was also an intrapersonal experience. That is, MHNs drew on psychological capabilities such as self‐regulation, cognitive appraisal, and self‐reflection to enact interpersonal and external boundaries between their work and their self. In turn, this contributed to their self‐efficacy and ability to proactively access personal and professional supports and resources that help them deal with emotionally challenging situations and maintain well‐being. Further, the process of enacting and maintaining intrapersonal boundaries allows MHNs to sustain the emotional balance required to positively adapt to emotionally adverse situations. Balancing professional boundaries and maintaining safe interpersonal boundaries have been previously identified in the literature as a protective factor in managing the EL of MH nursing work (Edward et al. 2017; Wilstrand et al. 2007). These new findings, however, identify that intrapersonal boundaries are essential for maintaining personal and professional equilibrium. This process could be further investigated in future research.

Another important finding in this study was that a key factor in building and maintaining MHNs' resilience beyond the personal efforts of MHNs, are organizations. Of importance, organizational support, resources, and the reduction of preventable workplace stressors (e.g., increasing work demands, high workloads, and lack of professional development opportunities/supports), are a major influence on MHNs' ability to adapt and maintain equilibrium. This is consistent with previous studies (Foster et al. 2018a, 2020, 2021; Hasan et al. 2018) that reported on MHNs' work‐related stressors. Workplace culture was also identified by MHNs in this study as a significant factor that can influence their resilience. For example, they referred to silent workplace cultures in which staff have no voice or influence in challenging practices or conditions that can deplete them, negatively impact their well‐being, and prevent them from effectively attending to their work. Further research is needed to explore workplace cultural, environmental, and/or team factors that contribute to MHNs' resilience and well‐being.

Limitations

This study was conducted with 11 Australian MHNs with high resilience and high EL. They may have different experiences and perspectives from other MHNs. Due to the Australian MH service context, findings may not necessarily be transferable to other countries.

CONCLUSION

Findings from this study demonstrate that to positively adapt to the EL of their work, MHNs engage in a range of self‐care strategies that allow them to replenish their mental and emotional energy and maintain intra‐ and inter‐personal boundaries. This process allows them to maintain equilibrium internally (mentally and emotionally) and maintain well‐being and professionalism. These findings highlight that MHNs’ well‐being is intrinsically linked to their capacity to self‐care and maintain the necessary boundaries required to adapt to emotional adversity at work. This study has also highlighted that organizational demands and workplace culture can negatively impact MHNs’ ability to maintain their energy, equilibrium, and well‐being.

RELEVANCE FOR CLINICAL PRACTICE

This study’s findings demonstrate that MHNs have the capacity to self‐manage and positively adapt in the face of emotional adversity to maintain their well‐being. This is linked to their ability to effectively remain therapeutic and professional in their interpersonal interactions. However, this process can be thwarted in an environment that does not support their well‐being. This emphasizes the need for organizations to proactively support MHNs’ resilience and well‐being by more closely reviewing, changing, and/or creating processes, policies, and procedures that better promote a physically and psychologically safe workplace, culture, and work‐life balance. This involves multi‐level strategies, ranging from clarifying expectations and/or work roles, to providing targeted well‐being and resilience education, and other professional supports such as clinical supervision, to build and strengthen MHNs' resilience and interpersonal practice capabilities. The ongoing EL of MH nursing work cannot remain invisible if MHNs are to make a meaningful difference in others' lives. Managers and organizations need to respond empathically to workplace challenges, including personal threats to staff well‐being, and provide supportive working environments.