WHAT CHARACTERISTICS ARE KEEPING NURSES FLOURISHING IN DIFFICULT ENVIRONMENTS: AN APPRECIATIVE INQUIRY STUDY by LAURA DEL RIO TORRES B.Sc.N, The University of Northern British Columbia, 2009 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES We accept this thesis as conforming to the required standard Dr. Landa Terblanche, Supervisor Dr. Sheryl Reimer-Kirkham, Second Reader Dr. Faith Richardson, Third Reader TRINITY WESTERN UNIVERSITY March 2019 © Laura Del Rio Del Rio Torres 1 ABSTRACT Many studies document the adversities facing nurses today. However, little research examines resiliency among nurses and their ability to flourish amidst these adversities. Using a qualitative method, this thesis aimed to address this gap by examining life-giving factors that allow nurses to be resilient and flourish in unhealthy environments. Using appreciative inquiry methodology, nine nurses working in British Columbia were interviewed. These interviews focused on their positive perspectives and experiences to identify life-giving factors influencing resiliency. Six themes were identified in the development of resiliency: personal life; a sense of purpose/calling; intrinsic characteristics; education and career opportunity; workplace culture, and reflection and self awareness. Resiliency can exist even if all six themes are not present; however, in order to flourish all six themes must be in a healthy state. This thesis provides practical wisdom that can be applied to all areas of nursing in order to promote resiliency and flourishing. Del Rio Torres 2 ACKNOWLEDGEMENTS Thank you to my Heavenly Father, who has walked by my side through every challenge that we have faced while I completed my graduate studies. I am grateful for His love, encouragement and a sense of peace that He gave me. Thank you Dr. Faith Richardson for your encouragement and wisdom; because of you my original topic was transformed into a positive inquiry resulting in practical research with an optimistic perspective - thank you. Thank you to my supervisory committee, Dr. Landa Terblanche and Dr. Sheryl ReimerKirkham who provided encouragement, support, patience and feedback during the completion of my thesis. Thank you to each participant that openly shared their stories with me. Thank you to my husband, Abraham, I could not have done this without you. Your love and dedication to our family is an inspiration. Del Rio Torres 3 TABLE OF CONTENTS ABSTRACT 1 ACKNOWLEDGEMENTS 2 TABLE OF CONTENTS 3 CHAPTER ONE: INTRODUCTION 8 Background: Relational Aggression and the Challenges in Nursing 8 Thesis Description 13 Purpose and Research Question 13 Thesis Method 13 Why is this Research Necessary? 14 Definitions 15 Relational Aggression and Workplace Aggression 15 Resilience 16 Flourishing 17 Outline of the Thesis 18 Chapter Summary 18 CHAPTER TWO: LITERATURE REVIEW 20 The Preliminary Scan of the Literature 20 Search and Retrieval Strategies 22 The Different Kinds of Literature 23 Literature Review: Summary of Related Evidence 24 Resilience in Nursing 25 International Resilience 25 Developing Resilience 26 Del Rio Torres 4 Flourishing in Nursing 27 Chapter Summary 27 CHAPTER THREE: RESEARCH DESIGN, METHODOLOGY, AND PROCEDURE 29 Research Design 29 Preliminary Fieldwork 30 Sampling 30 Recruitment and Encountered Challenges 31 Data Collection Methods Demographic and Nursing History Survey 32 32 Reason to Become a Nurse 33 Current Area of Practice 34 Positive and Negative Factors 35 In-Depth Semi-Structured Interviews 36 Field Notes 37 Reflexivity 39 Data Management 39 Data Analysis 40 Creating Categories 40 Topic Coding 40 Ensuring Credibility, Dependability, Confirmabilty and Transferability 41 Ethical Considerations 42 Chapter Summary 42 CHAPTER FOUR: FINDINGS 44 Del Rio Torres 5 Model of Resilience and Flourishing 44 Personal Life 45 Self Care 45 Faith 46 Family First 46 Family Challenges Sense of Purpose/Calling 47 49 Source 49 Expression 50 Outcome 52 Intrinsic Characteristics 52 Positivity 52 Dedicated and Unrelenting Spirit 54 Caring 56 Education and Career Opportunities 58 Education Advocacy 59 Lessons Learned 61 Opportunities in Nursing 62 Workplace Culture 64 Teamwork 64 A Safe Environment 67 Leadership 69 Frontline Leadership 70 Del Rio Torres 6 Manager 72 Reflection and Self-Awareness 73 Developing Reflection and Self-Awareness 76 Knowing Oneself 77 Flourishing 78 Chapter Summary 80 CHAPTER FIVE: DISCUSSION 82 Review of the Problem 82 What the Literature Says 83 Self Care 83 Sense of Purpose/Calling 85 Workplace Culture 87 Reflection and Self-Awareness 91 What my Study Adds to Literature 93 Chapter Summary 94 CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS 95 Summary Review and Key Findings 95 Recommendations 96 Research 96 Leadership/Administration 97 Implications for the Individual Practice 100 Policy 101 Education 102 Del Rio Torres 7 Limitations 102 Summary of Thesis 103 REFERENCES 104 Appendix A: Table Outlining the Preliminary Literature Review 111 Appendix B: Demographic and Participant Nursing History Survey 114 Appendix C: Brochure for Participants 117 Appendix D: Interview Questions 119 Appendix E: Pictorial Diagram on Resilience and Flourishing 120 Del Rio Torres 8 CHAPTER ONE: INTRODUCTION Nursing in the twenty first century is complex, challenging and rewarding (Glass, 2009; Morley & Burns, 2016). A nurse is at the bedside from birth to death and everything in between. To be a nurse in an affirming work environment is already challenging, but today nurses are facing many adversities that increase challenges in the working environment (Advisory Committee on Health Human Resources, 2002; Ditmer, 2010; Eggertson, 2011). Throughout North America, nurses are experiencing high volumes of burnout and compassion fatigue resulting in nurses leaving the profession. That new graduates are leaving nursing is frequently mentioned in current research (Chachula, Myrick, & Yonge, 2015; Eggertson, 2011). But yet, through these challenges, some nurses are able to do more than survive in their workplace setting - some nurses flourish in the midst of a toxic work culture. However, little research identifies the life-giving factors that nurses use to fuel resilience and enable them to flourish in an unhealthy workplace environment. The first and most important objective of my research is to learn from nurses about these life-giving factors or core values that give them resilience to not only survive but flourish in a difficult environment. Secondly, my thesis will establish a framework for individual nurses and employers to utilize to foster a positive culture that enables nurses to not only be resilient but to flourish in their working environment. Background: Relational Aggression and the Challenges in Nursing In order to understand the value of the life-giving qualities that enable nurses to flourish, it is essential to recognize the many reasons why they require resilience to continue doing their job well and to experience purpose and meaning in their work. Several factors negatively influence the working environment for nurses today. Del Rio Torres 9 Over time different stereotypes of nurses have developed, many of which are negative. The public's perception of nursing varies, often including the following view of nurses: those who care for others in distressing events; doctor's assistants; 'bedpan and sponge bath warriors'; those who give medications as 'ordered'; those who just give basic wound care; and advocates ensuring the welfare of the patient (American Society of Registered Nurses, 2007). For example, in an astonishing display of ignorance about nursing and nurses’ work, Joy Behar, a TV host on "The View" questioned why a nurse would wear a 'doctor's' stethoscope (September 2015). After a vast outcry from nurses worldwide, she made an apathetic apology while still referring to a nurse's uniform as a costume (Lee, 2015). It is clear the public opinion is greatly influenced by media. However, despite these stereotypical images, the profession of nursing is still routinely viewed as trustworthy, according to annual polls by the American organization Gallup (Riffkin, 2014). While nurses might experience difficulty given these stereotypes, they encounter more direct challenges in the field, including budgets cuts, short staffing, aggressive patients and secondary trauma caused by stress and injury. Morley and Burns define secondary trauma as "confronting unfixable suffering/moral distress" (2016, p. 8). On a daily basis, nurses and other health professionals walk alongside patients, witnessing their firsthand experiences of trauma and vicariously experiencing their suffering. Secondary trauma signs and symptoms imitate posttraumatic stress disorder (Morley & Burns, 2016). In addition to their physically and mentally draining responsibilities, nurses often witness or experience aggression from patients and colleagues. A well-known phenomenon within the profession is that "nurses eat their young" (Ditmer, 2010; Staples, 2012). This phenomenon is demonstrated when senior nurses do not assist new nurses but make their initial experiences Del Rio Torres 10 unnecessarily difficult. However, we cannot assume that relational aggression is solely horizontal between nurses. Much research provides evidence of relational aggression between many different healthcare professionals. Due to the negative work place environment that nurses are working within, research conducted by Twibell et al. (2012) found that 30% of nurses in the United States will leave nursing within the first year and 57% will leave within their second year of employment. To understand relational aggression, one must look beyond nursing, as bullying and harassment are common throughout all healthcare professions (Vessey, DeMarco, & DiFazio, 2011). Sources of harassment include but are not limited to managers, physicians, pharmacists and administrators (Ditmer, 2010). The Center for American Nurses states that "[l]ateral violence and bullying has been extensively reported and documented among healthcare professionals, with serious negative outcomes for registered nurses, their patients and health care employers" (2008, p. 1). In fact, 75%-80% of nurses have experienced harassment, intimidation and bullying during their career (Ditmer, 2010). Another related concern is the accepted culture within nursing. Physical and verbal abuse from a patient or a patient's family member is typically accepted as 'part of our job' (Brunt, 2011). In a survey completed by nurses from Alberta and British Columbia, 46% admitted to experiencing some sort of violence during their previous five shifts (Duncan et al., 2001). As a Violence Prevention facilitator, using the Violence Prevention curriculum, I have discussed with health care providers the importance of reporting abuse from patients and their family members. The majority of the health care providers are surprised they must not only report incidents where they were physically hurt, but also "near misses" and incidences potentially causing physiological harm. Healthcare professionals have also excused inappropriate behaviour Del Rio Torres 11 because the patient was not in a healthy state of mind. Relational aggression is underreported in nursing (Brunt, 2011; Ditmer, 2010; Vessey et al., 2011). Vessey et al. discussed the well established 'code of silence' (2011). This code is demonstrated by a particular RN's experience as a fairly new grad [her name has been changed to maintain confidentiality]. Sara became clearly upset after having a physician shout at her in front of her colleagues about a patient's parencentesis, doubt her knowledge and invade her personal space. Sara stated, "...I found my charge nurse and I told her. And she pulled me over and said you know he made me cry many times, so that's him. Don't worry about it" (Smith, personal communication, December 1, 2015). Sara was not encouraged to report this incident but to 'let it go'. Nurses may also avoid reporting relational aggression because of their fear that the bully may retaliate, especially if he or she is a co-worker or a manager. There is little education about the process of how to report relational aggression (Ditmer, 2010; Vessey et al., 2011). Although underreported, relational aggression affects psychological and physical health, whether short term or long term (Ditmer, 2010; Safe Work Australia, 2013). Psychological symptoms include but are not limited to anxiety and panic attacks, depression, decrease or loss of confidence and mood swings. Physical symptoms may include an inability to sleep, headaches, hypertension, and anorexia. Unfortunately, a long-term effect may be post traumatic stress disorder (Hubbard, 2014; Vessey et al., 2011). After Sara had several experiences of bullying and relational aggression as a newly graduated nurse she experienced shakiness, anxiety, and a poor sleep pattern (Smith, personal communication, December 1, 2015). As a consequence of relational aggression, Sara is not alone in the struggle with the psychological and physical effects of relational aggression; an immediate outcome is that the patient is directly or indirectly Del Rio Torres 12 impacted. Thus, relational aggression negatively effects the quality of patient care and arguably, patient outcomes (Ditmer, 2010; Duncan et al., 2001). Bringing the research closer to home, I have been nursing since 2009. I have experienced verbal aggression from doctors and nurses that I let "roll off my back". I needed more time to heal from some relational aggression experiences than from others. Recently, I experienced the psychological and physical symptoms caused by bullying within the workplace. I could not identify the relational aggression within the workplace climate I was experiencing until I was physically and mentally unable to function in all aspects of my life. My family was shocked to see an unknown person evolve. I was experiencing anxiety, depression, sleep disturbances, constant crying and an inability to cope at work and in my personal life. Despite my lack of full understanding of what was occurring to me, I began the process of reporting the maltreatment. Unfortunately, Work Safe BC denied my claim because the bullying was not witnessed. Thus, I have personally learned that relational aggression is difficult to prove. This reality, of course, increases the fear of reporting it, especially when the victim is in an unhealthy state of mind. When I returned to work, I experienced a hostile and unhealthy environment. For my psychological and physical health, I chose another position at a different site. Because of my faith in God, professional counseling, my supportive family, and determination, I slowly recovered; however, not everyone is able to recover and remain in nursing. Despite relational aggression being difficult to prove, it is recognized by many different organizations. The Canadian Nurses Association and the Canadian Federation of Nurses Union have established a Joint Positional Statement on violence and bullying in the workplace (2015). They advocate for workplaces to be free of violence and bullying. The British Columbia Nurses Union (BCNU) has initiated an anti-bullying campaign for nurses (2015). Different health Del Rio Torres 13 authorities have also initiated respectful workplace policies. Recently Worksafe BC has created an area on its website with resources to assist with what has been called an epidemic of workplace violence (2016). It is evident that nurses currently work in challenging environments. Nurses face negative public opinions, budget cuts, short staffing, aggressive patients, secondary trauma, relational aggression, and an accepted culture of aggression. The fact that many nurses are resilient and able to flourish within nursing is significant, but the phenomenon is under-studied and not well understood. Thesis Description Purpose and Research Question To address this gap in knowledge, the purpose of this thesis was to understand the lifegiving factors that allow nurses to be resilient and flourish in an environment filled with relational aggression, conflict, and other challenging factors. The aim of my research was to identify the factors that individual nurses recognize as supporting resilience and flourishing in the workplace and to develop a framework of resilience that encourages flourishing. The research questions were as follows: 1. What are the core values and individual characteristics that allow nurses to persevere through adversity such as relational aggression in the workplace? 2. What are the elements that make up the support systems and other external factors that allow nurses to "bounce back" and flourish in both good and bad times in the workplace? Thesis Method Appreciative Inquiry was selected as the method by which to explore these research questions. Ten nurses were interviewed to gain their perspectives on resilience in the context of Del Rio Torres 14 relational aggression in the workplace, and qualitative methods of data analysis were applied to interpret the findings. Why is this Research Necessary? Many nurses are faced with unhealthy working environments influenced by numerous factors such as staffing shortages, violence and relational aggression. Unfortunately, due to these challenges, some nurses are not surviving; they are resigning from their positions or leaving the profession completely. However, throughout these adversities, some nurses are able to rise above the negative environment with resilience and thus flourish in their nursing. In this study, I aim to uncover some of the hidden qualities and characteristics allowing nurses to establish resilience and flourish. This research brings awareness to the concepts of resilience and flourishing. The first step in my research was to identify resilience and flourishing. Once these factors had been identified, they can be added to what little research on the topic is currently available in the nursing literature. There are two groups that may be influenced by this research. The first is frontline staff working in an unhealthy environment. They may begin to consider the process of either identifying or establishing their own resilience. The second group that could benefit from this research are employers. They can choose to encourage their departments to support the lifegiving factors that support resilience, ultimately facilitating the flourishing of nurses on their units. By choosing to support life-giving characteristics, they can begin to change the environment in addition to supporting their employees in the process of building resilience and in encouraging them to flourish. In the end, everyone benefits. Individual nurses are able to thrive not only because of their own life-giving factors, but also because they feel supported in their working environment. The employers will benefit when nurses continue employment in their Del Rio Torres 15 departments, and the patients will have nurses who give excellent care unhindered by the psychological and physical effects of relational aggression. Definitions The following definitions are used in this thesis. Relational Aggression and Workplace Aggression Relational aggression (RA) includes: - horizontal violence involves offensive, humiliating and persistent violence manifested verbally or non-verbally (Brunt, 2015, Center for American Nurses, 2008). Horizontal violence occurs between colleagues in similar positions (e.g. nurse to nurse). - lateral violence also is offensive, humiliating and persistent violence either verbally or nonverbally. However, lateral violence occurs between different positions within the organization (e.g. manager to nurse) (Canadian Nurses Association & Canadian Federation of Nurses Union, 2015) - bullying is persistent, unreasonable abuse, including intimidation and insulting behaviours or remarks, resulting in an abuse of power that causes victims to feel humiliated, threatened, and vulnerable, undermining their self-confidence (Brunt, 2015, Center for American Nurses, 2008, Safe Work Australia, 2013). -harassment often occurs because of differences such as, gender, race, background or age (Vessey et al., 2011). The definition of/for RA incorporates the above terms. RA includes but is not limited to gossip, manipulation, intimidation, threats, exclusion, ridicule or unkind criticism, verbal aggression portrayed as a joke, and betrayed confidences (Dellasega, 2011). All of the above can happen in an overt or covert form Del Rio Torres 16 - overt forms of aggression are easily witnessed and therefore easier to assess help or resources if required. WorkSafe BC accepts overt forms as valid because they are witnessed by other people (2016). However, a second form of overt RA is when witnesses, also known as bystanders of the aggression, remain silent and do not advocate for the victim. - covert forms of aggression are not openly displaced for others to see, therefore, it is difficult to access help or resources if required. - Workplace aggression is similar to RA but happens only in the workplace. A nurse may be hit, kicked or physically assaulted, as well as verbally assaulted by the patient or the patient's family members. In this paper, relational and workplace aggression (RWA) will represent all forms of workplace violence. Resilience In a difficult work environment, nurses require resilience to survive. Resilience is defined as the ability to "bounce back"; the ability to cope successfully through challenges or trauma; the ability to work through setbacks and transform them into an opportunity to grow; and the ability to overcome challenges (Edward, 2005; Gillespie, Chaboyer, & Wallis, 2007; Hart, Brannan, & De Chesnay, 2014). The British Columbia Nurses Union facilitates a course called the Personal Resilience Workshop. The presenters discuss why resilience is an essential characteristic for those working in healthcare because of many risk factors. They list eleven different aspects of resilience: 1. adapt to change easily; 2. feel in control of life; 3. bounce back after hardship/illness; 4. have close dependable relationships; Del Rio Torres 17 5. be optimistic; 6. know where to turn for help; 7. think clearly/logically under pressure; 8. see the humour in situations, even under stress; 9. be self-confident and feel strong as a person; 10. believe things happen for a reason; 11. handle uncertainty or unpleasant feelings (Morley & Burns, 2016, slide 16). Throughout the course, different strategies for individuals to build or develop their own form of resilience are discussed. An individual who is resilient has the ability to cope well with significant change, adversity, risk or stress (McDonald, Jackson, Vickers, & Wilkes, 2016). For this thesis, resilience will be defined as an adaptive life skill that helps nurses "bounce back", that is, to develop the ability to cope successfully with challenges and adversity; to work through setbacks and transform them into an opportunity to grow; and to overcome challenges and protect against emotional exhaustion. This definition is a synopsis of the definitions presented in the literature review (Chapter 2). Flourishing In a profession where change seems the only constant, some resilient nurses are flourishing in their profession. However, little information in the literature defines the concept of flourishing, although research at times refers to it as thriving. Thriving is defined as "...the capacity to lead in dynamic nursing roles and direct changes to practice within challenging nursing environments" (McDonald et al., 2016, p. 124). In a professional practice model, Jacobs discusses how flourishing is influenced by three ideas: goods of the body, goods of the soul and external goods (2013). An essential aspect of thriving involves not only coping through Del Rio Torres 18 adversity but also positively changing the outcomes of difficult circumstances (McDonald et al., 2016, p. 124). Flourishing, involving happiness and well-being, should be the ultimate aim of the practice development process (Yalden & McCormack, 2010). According to Knowles "These individuals appear to be more present or future oriented, hopeful, and possess traits of transcendence, overcoming and forgiveness" (2011, p. 58). For this paper, flourishing and thriving will be interchangeable and defined as the ability to be resilient and to continue to find purpose, passion or joy in nursing. Outline of the Thesis In the next chapter, a review of relevant literature is presented. In Chapter Three the research design, methodology and procedure are explained. In Chapter Four the findings from the data are presented along with a pictorial graph representing the data. In Chapter Five all of the data and literature are collaborated in a discussion, and Chapter Six presents the study conclusion as well as recommendations. Chapter Summary Nursing continues to be a trusted profession that provides care for numerous patients, clients and families. Nurses today are facing many adversities on a regular basis, increasing their already complex and challenging environment. These factors results in burnout and compassion fatigue with too many nurses leaving the profession. As nurses face these adversities, some nurses are only able to survive in their workplace, while other nurses are able to flourish amidst challenging circumstances. Little research identifies the life-giving factors that enable nurses to build up resilience and flourish in their workplace. Through my research, I learned from nurses about the life-giving factors, or core values that enable flourishing and thriving. Using the positive aspects of flourishing, I have developed a practical framework that individual nurses or Del Rio Torres 19 employers may use to cultivate resilience and flourishing in nurses' personal life and professional work environment. Del Rio Torres 20 CHAPTER TWO: LITERATURE REVIEW The purpose of this literature review is to gain an understanding of the existing evidence on the topic, including identifying and reviewing published work and also revealing gaps in the research. Achieving a thorough literature review in a qualitative study has been debated "...because prior studies could influence conceptualization of the focal phenomenon" (Polit & Beck, 2012, p. 61). Nonetheless, I conducted several detailed literature searches prior to developing the research question, to create awareness on the topic and to avoid repeating saturated research. The Preliminary Scan of the Literature The initial topic of interest was workplace violence including bullying. Two separate literature searches using CINAHL on violence in healthcare settings were completed in October 2015. The second search included a broader range of search terms encompassing all forms of violence in healthcare settings. There was plenty of research dedicated to examining horizontal and vertical violence, bullying, and harassment in the workplace. These forms of violence have been present in nursing for many years prior to the beginning of discussions about them (Fudge, 2006). Horizontal and vertical violence, bullying and harassment negatively impact an individual's psychological well-being as well as an employer's ability to retain staff; both result in decreased levels of patient satisfaction and fewer positive outcomes (Ditmer, 2010; Hubbard, 2014). Hubbard discussed how horizontal violence continues despite zero tolerance policies. The following recommendations to reduce relational and workplace aggression appear in research: enforcing the zero-tolerance policy against violence; leadership support for healthy workplaces; a mandatory reporting system of all events; mentorship programs; education and support and debriefing post incidence (Ditmer, 2010; Fudge, 2006). Del Rio Torres 21 Given the well-known evidence of this phenomenon, many organizations have taken a stance in hopes of educating and creating awareness and thus decreasing the relational aggression within the organization. Health authorities have also initiated respectful workplace policies. In an effort to improve the workplace, Fraser Health Authority displayed many posters around its facilities promoting a respectful environment free of bullying and harassment and has also provided education on how to report incidences involving violence and RA. The Violence Prevention Program Leader in Workplace Health for Fraser Health Authority has witnessed a dramatic increase in reports by employees documenting RA from colleagues, patients and family members, resulting in an effective education roll out (Mercado-Mallari, personal communication, July 25, 2016). The anti-bullying and harassment concept is also supported by Worksafe BC, which has created an area on its website with resources to assist with what has been called an epidemic of workplace violence (Worksafe BC, 2016). The literature review revealed that this phenomenon in nursing is well documented, with few remaining gaps. It also demonstrated the concerted efforts of many organizations to create a healthy environment for their employees. Thus, data saturation has been met. Data saturation "...occurs when themes and categories in the data become repetitive and redundant, such that no new information can be gleaned by further data collection" (Polit & Beck, 2012, p. 62). This saturation demonstrates the necessity for an initial literature search to gain an understanding of current gaps in research. Therefore, for this thesis a positive approach was chosen to examine resilience in nursing and the core values and characteristics that enable nurses to flourish in an environment with many factors that negatively affect their working environment. Del Rio Torres 22 Search and Retrieval Strategies I used Boolean terms in my literature review to assess both current knowledge and gaps in research about nurses' development of resilience that allows them to flourish in their working environments (Appendix A). Initially, in January 2016 I used the Business Source Complete and PsychINFO databases to scope out appropriate terminology and to establish a baseline for flourishing in the nursing environment. This data search revealed that keywords such as "climate", "environment", and "culture" primarily referred to the outdoor environment. The Business Source Complete search located 75,174 articles using the term "nurs*" and only 5,492 using "flourish*". The two limiters that were applied at this point in the search were articles in English only and articles no older than the year 2000. When the two search terms were combined, only twenty-three articles emerged; none of these articles were chosen for review because the articles were related to landscaping and nurseries. In comparison, the PsychINFO search had 126,097 articles with the search term "nurs*" and only 3,253 with "flourish*". When the search terms were combined, 108 articles were located consisting of a wide array of topics, and of those, six articles were chosen for review. The next data search strategy, in March 2016, involved CINAHL. The purpose of this search done using previously identified research terms, including RA and workplace aggression, was to look for updated research after the initial search in October 2015. CINAHL located 715,307 articles using the search term "nurs*". There were 14,630 articles using the terms "bull*", "harass*", "horizontal violence", "lateral violence", "relational aggression", and "workplace aggression". When I applied the same limiters as in the previous search and then combined the two searches, 2,189 articles appeared. Because the topic was already well researched, two more limiters were applied to help identify the most relevant research, namely Del Rio Torres 23 articles that were peer reviewed and from Canada. The result was 49 articles including personal stories and opinions, medication administration practices and leadership. Of these, three articles were chosen to identify negative outcomes for individual nurses and patients that can result from RA. The final literature review in March 2016 was conducted using CINAHL to identify resilience enabling nurses to flourish within an unhealthy workplace. CINAHL produced multiple articles using the search term "nurs*". The next search used the terms "flourish*" and "resilien*" resulting in 6,515 articles. The final search used the terms "workplace, climate, culture, environment, hospital and healthcare," resulting in 775,836 articles. Prior to the application of the limiters, the three searches yielded 456 articles; after the limiters 380 articles remained. Among the 380 were articles discussing resilience during natural disasters as well as during and after different warfare situations. Even though the articles were powerful and thought provoking, most of them were not relevant for my thesis, because of the extraneous situations. Finally, I chose ten articles that were most closely related to my topic. The Different Kinds of Literature At the beginning of the research process, different policies and protocols from several organizations supporting nurses and from workplaces hiring nurses were reviewed. The findings were relevant to this study. The Canadian Nurses Association and the Canadian Federation of Nurses Union have developed a joint position statement declaring their belief in and desire for violence free workplaces (Canadian Nurses Association & Canadian Federation of Nurses Union, 2015). BCNU also advocates for a healthy environment free of violence. It initiated an antibullying campaign in 2015 to supporting its nurses. Worksafe BC states "Employers must provide a workplace as safe from the threat of violence as possible. If there is a risk of violence Del Rio Torres 24 in a workplace, the employer must set up and instruct workers on procedures to eliminate or minimize the risks" (Worksafe BC, 2016). Finally, different health authorities across British Columbia are implementing education about violence and educating staff on how to report different acts of violence, including verbal abuse (Mercado-Mallari, personal communication, July 25, 2016). The kinds of literature reviewed after the intensive searches above included journal articles, a doctoral study, literature reviews, and several discussion articles. Several of the journal articles were primary research. One journal article researched nurses within British Columbia and Alberta, and another article focused on Canadian nurses, increasing my understanding of the issues facing nurses in British Columbia. Literature Review: Summary of Related Evidence The literature review highlighted three interrelated concepts related to resilience and flourishing in nursing, as response to workplace violence. First, it confirmed that nurses today are facing adversity in their workplaces. Some challenges include inadequate support; insufficient staffing; high patient acuities; an increasing workload; demanding environments; unsafe and demanding work environments; psychological emptiness; and unhealthy work cultures (Hart et al., 2014; Lowe, 2013; Rushton, Batcheller, Schroeder, & Donohue, 2015; Scholes, 2013). These pressures and adversities that nurses are facing result in burnout (Rushton et al., 2015). The second topic in the literature was resilience. The literature related to resilience is discussed in detail below. The third concept relates to flourishing. Notably, significantly more research exists on resilience than on flourishing. Del Rio Torres 25 Resilience in Nursing Even though it is not clearly defined in the literature, resilience is essential for nurses who not only face adversities in nursing but in every day practices (Glass, 2009). Rushton et al. (2015) found that resilience decreased burnout, protected nurses from emotional exhaustion and contributed to their capacity to achieve personal accomplishments. The majority of research refers to resilience as a characteristic or attribute that is developed and learned with time and adversity (Gillespie et al., 2007; Glass, 2009; Grafton, Gillespie, & Henderson, 2010; Lowe, 2013; Rushton et al., 2015). As discussed in Chapter One, resilience is an adaptive skill differing from person to person (Scholes, 2013) and can be defined as the ability to "bounce back", to cope successfully through challenges and adversity, to be able to work through setbacks and transform them into an opportunity to grow, and the ability to overcome challenges, thus protecting against emotional exhaustion (Edward, 2005; Hart et al., 2014; Lowe, 2013; McDonald et al., 2016; Scholes, 2013). The research identified numerous attributes influencing resilience. Resilience is influenced by hope, a sense of meaning or purpose in life, a sense of value in life, optimism, selfefficacy, coping ability, self-control, competency, flexibility, adaptability, patience, faith, hardiness, critical reflection, a support network and a spiritual frame of reference (Gillespie et al., 2007; Glass, 2009; Grafton et al., 2010; Hart et al., 2014; Lowe, 2013; McDonald et al., 2016; Rushton et al., 2015). The significance of resilience is demonstrated through its outcomes. Resilience provides individuals with the ability to navigate through adversities while protecting themselves from emotional exhaustion and burnout. Through the reframing of their negative experiences, these individuals can achieve personal accomplishments, gain self control, and experience Del Rio Torres 26 psychological empowerment as well as personal growth (Edward, 2005; Gillespie et al., 2007; Rushton et al., 2015; Simoni, Larrabee, Birkhimer Mott, & Gladden, 2004). International Resilience. Aware of the challenging workplace environments facing nurses and midwives, Glass (2009) studied their resilience, hope, and optimism in the workplace in England, Scotland and New Zealand. Initial findings revealed an equation: challenging workplace environments + psychological "emptiness" + diminished inner balance = the need for resilience. The participants in this project struggled to define resilience but were able to identify resilience as related to being "stripped bare" or psychologically empty and as essential for inner balance, survival and sanity. Two other beneficial tools mentioned were cognitive reframing (a shift in mindset to help an individual deal with all situations) and the ability to ground oneself with positive connections. Within the phenomenological methodology, Edward (2005) investigated resilience in crisis care mental health clinicians in Australia through qualitative interviews. Edward found that "...resilience as a coping strategy may permit people to develop confidence in effectively dealing with changes, reframing negative experiences into positive and self-enhancing ones, and creating positive outcomes" (p. 147). Resilience is an international concept for healthcare providers. Developing Resilience. The development of resilience is an individually learned skill developed over time and through adversity. In a conceptual analysis, Gillespie et al. (2007) discussed four criteria for resilience to develop: first the existence of adversity; second, either a physical or psychological understanding of the adversity as traumatic; third, the intellectual capacity to interpret adversity both cognitively and socially; and, finally, a realistic world view which is not a false optimism or a pessimistic attitude. Scholes (2013) discussed self care as an essential aspect to develop resilience. Examples of self care include exercise; a well-balanced Del Rio Torres 27 diet; work life balance; adequate sleep and rest; the ability to laugh and learn; the ability to share problems and voice concerns; supportive networks; choosing the correct battle to fight; and separating work stress and home stress. However, the responsibility for building resilience lies not only with the individual nurse but also with administration and management. They must encourage and foster a positive and supportive environment as well as develop programs or strategies that will build resilience within employees in their departments (Grafton et al., 2010; Hart et al., 2014; Lowe, 2013; McDonald et al., 2016). Flourishing in Nursing In a literature review, Lowe (2013) addressed the fact that regardless of the devastating effects of stressful environments, some nurses are able to flourish within workplace adversity while also delivering high quality patient care. Lowe identified this ability to flourish and thrive as resilience. He defined thriving being adaptive in the face of adversity and resilience as a learned skill that protects against emotional exhaustion and decreases burnout. In a qualitative study, McDonald et al. (2016) briefly touched on the concepts of thriving and flourishing and note that healthcare professionals who are thriving or flourishing have a high level of job satisfaction, optimism, a sense of belonging, group cohesiveness, and clinical competence. They found that thriving requires self-efficacy, defined as a strong belief that an individual can not only cope with adversity but also positively change the situational outcomes as well as having the capacity to lead in dynamic nursing roles and to direct practice changes within challenging environments. Chapter Summary The process of this literature review enabled a change in direction in my chosen research topic. Relational and workplace aggression in nursing has already been thoroughly researched. Del Rio Torres 28 Acknowledging this data saturation, this research changed directions, taking a positive approach to investigate how nurses are able to be resilient and flourish in adversity and challenging environments. My initial literature review provided a detailed understanding of the complexities and challenges nurses are facing on a daily basis. Even though nurses are working in unhealthy environments, some are rising above the adversities: and their nursing practices are flourishing. This examination of flourishing is unchartered waters in the literature - the concept of resilience has been researched somewhat but not the ability of nurses to flourish during adversity. Little research explores or defines flourishing, making it difficult to discover a consistent, credible theme. Therefore, the end goal of this thesis is to fill a gap within this essential topic. It is also important that this research provide a richer understanding of the different life-giving factors that nurses identify as fundamental to flourishing in difficult workplaces. Building on these themes, a framework empowering resilience and flourishing in the workplace will be developed. Chapter Three discusses the research design, methodology and process of this thesis. Del Rio Torres 29 CHATPER THREE: RESEARCH DESIGN, METHODOLOGY, AND PROCEDURE This chapter begins with an overview of the research design and the plan for the initial study. Next, it reviews the requirements of the sample and the process of recruitment, as well as the challenges involved. Thirdly, the chapter discusses the different data collection methods used, and demonstrates a respectful process for managing the data. Once the data was compiled, the process of analysis began with categorizing the data and later organizing into the codes. Finally, the chapter discusses how the requirements for rigour and ethical considerations were met for the duration of the research. Research Design Appreciative Inquiry is a research concept and approach focusing on the positive aspects of solutions to the problems: "It moves toward what the organization is doing right and provides a frame for creating an imagined future that builds on and expands the joyful and life-giving realities as the metaphor and organizing principle of the organization" (Magruder Watkins & Cooperrider, 2000, p. 1). Dr. Faith Richardson (2015) effectively explains the concept of Appreciative Inquiry. To appreciate is to look at the best in the people and situations around us. A common viewpoint is seeing the glass half full. Inquiry is to explore, to ask questions, and to be open to seeing new possibilities. To inquire is an intervention: change starts the moment the question is asked: when questions are asked in a positive approach, the process of change has a greater and longer lasting effect. Appreciative Inquiry involves a continuous cycle comprising of four questions (Richardson, 2015). My research incorporates these questions, which will be discussed later. Del Rio Torres 30 Preliminary Fieldwork Initial fieldwork is important for understanding the culture of, and the concerns facing the population prior to the completion of the study. It may also be referred to as clinical fieldwork in which the researcher spends time observing the current practices and discussing the concerns with healthcare professionals (Polit & Beck, 2012). My fieldwork was not formally a part of my research ethics application, thus my fieldwork provides a background to my thesis. I observed and discussed my own acute care work environment with my colleagues. Through an interview with a colleague about her experience as a new graduate, I was challenged and encouraged to create changes that could potentially make a difference for nurses. I am also a facilitator for the Violence Prevention curriculum of Fraser Health. One aspect of the curriculum is to advocate for employees and to report abusive behaviours from patients, their families, and colleagues. Many colleagues shared about experiencing a workplace culture where violence was underreported and tolerated as a part of the job. Finally, my personal experience of being bullied at work and its devastating effect on me changed my perspective. Through a personal conversation with my supervisor, Dr. Faith Richardson, I was challenged to investigate using the Appreciative Inquiry method to focus on the positive side of things in order to make a difference. Sampling Prior to specifying the sample plan, it was necessary to identify the focused population: "A population is all the individuals or objects with common, defining characteristics" (Polit & Beck, 2012, p. 59). The literature research demonstrated that nurses are facing numerous challenges (Hart et al, 2014; Lowe, 2013; Rushton et al., 2015; Scholes, 2013). In order to narrow down the vast population, my targeted population had three requirements: nurses who had lived in BC during the last two years, who had a minimum of three years of nursing experience, and who had Del Rio Torres 31 worked in an acute setting within the last two years. The next step was to design the sampling plan. According to Polit & Beck, "The sampling plan specifies how the sample will be selected and recruited, and how many subjects there will be" (2012, p. 59). The ideal population would be eight to ten nurses working in different acute care areas as well as different hospitals. There were four different methods of recruitment. First, I posted a recruitment poster on the Trinity Western University MSN Homepage. Second, I created a Facebook page in order to publicize my research. The third method was word of mouth in hopes of recruiting participants through my network of colleagues from the past and present. And finally, I hoped a snowball effect would spread the information through word of mouth to participants I did not know. Recruitment and Encountered Challenges When I began the process, I did not expect to have participants from outside Metro Vancouver, which is the vicinity of the University. However, the first two participants who volunteered lived on Vancouver Island. It was not realistic for me to travel to the island to interview the nurses, requiring me to seek permission from the Ethics board to interview the participants over the phone and gather data from another health authority. Another challenge I faced was with my colleagues. Prior to the interview stage, I had many conversations with my colleagues about my research, but at the appropriate time none of my colleagues offered to be participants, and I did not want to ask specific colleagues in case I initiated bias. After I had completed four interviews, a colleague posted my poster on her Facebook page and asked several of her nursing school friends if they would be interested in participating. Through a snowball effect, five nurses agreed to participate. The snowball effect is when participants are recruited through word of mouth and previous participants (Polit & Beck, 2012). I completed nine interviews in total and then began the coding process. At this stage, I had several friends and Del Rio Torres 32 colleagues specifically ask why I did not directly ask them -- I responded that I did not want to interview my current colleagues with the possibility of introducing my own bias in my thesis. Data Collection Methods Data collection is gathering information to address a research concern or problem (Polit & Beck, 2012). This study collected data through several different methods. The first strategy was to have each participant complete the "Demographic and Participant Nursing History Survey" (Appendix B). The second strategy was a semi-structured interview with participants using the "Four-D" process from the Appreciative Inquiry method. The third strategy, generating reflexive field notes, occurred after each interview and documented the participant's behaviours and activities along with my personal thoughts about the interviews. Initially, to allow for "participant member checking", the final strategy was to invite all the participants to a nonobligatory group interview in which I would present the initial themes and ideas. Because of the diverse geographical locations of the nine participants, this method was not realistic and needed to be re-evaluated. Instead a brochure (Appendix C) was created and emailed to each participant, to allow "participant member checking" to occur. Demographic and Nursing History Survey The survey, which was completed at the beginning of each interview, was a questionnaire providing a baseline of information from each participant. The results of the survey are summarized here, to provide a description of the study sample. The nine participants represented three different health authorities within British Columbia: Fraser Health Authority, Vancouver Coastal Health Authority and Vancouver Island Health Authority. The majority of the participants were between the ages of twenty and forty, while one participant was between fiftyone and sixty. Eight of the participants were female while one was male. Of the nine Del Rio Torres 33 participants, eight had completed their degree and were Registered Nurses (RNs), and one was a Licensed Practical Nurse (LPN). Five of the RNs had completed a certificate in a specialized area while the other four had completed a variety of additional educational courses or seminars during their nursing careers. One participant had been practicing between three to five years, three between six and ten years, four between eleven and fifteen, and one between sixteen and twenty years. Of the nine participants, four worked full time, four worked part time, and one worked as a casual. The survey established the multiple areas of experience represented by the nine participants. Eight of the nine participants had worked in a medical/surgical unit. Four of the participants worked on a cardiac unit. Three of the participants had worked in emergency and three in a critical care or an intensive care unit. Other areas of experience included endoscopy, leadership, sub acute, oncology, palliative, surgical day care, addictions/mental health, and vascular. The nine participants were experienced and well-educated nurses (Appendix B). Reason to Become a Nurse. The survey asked the participants what aspects drew them into nursing. The multiple-choice questionnaire gave multiple options for each question and an additional category where participants could enter other reasons. Each participant identified being drawn into nursing because of a desire to help others. Six of the participants choose nursing because it provided an opportunity to make a difference, because of the science behind nursing, and because of the various working opportunities within nursing. Five of the nine participants choose nursing because of job security. Other categories that were chosen included nursing as a trusted profession, flexibility, money, and the opportunity for further education. The two added reasons were the pension plan and a lifetime desire to be a nurse. Of the nine participants none was influenced to become a nurse by having family members who were nurses. Del Rio Torres 34 Regardless of the challenges nurses face, each participant was drawn into nursing because of the desire to make a difference (Appendix B). Current Area of Practice. The participants were asked to identify their current area of practice and the length of time in the area. Of the nine participants, there were fourteen different areas of current practice. Three of the nine were working on a medical unit, and two were working in an emergency department. The other areas of practice included high acuity, intensive care, telemetry, palliative, oncology, cardiac, haemodialysis, and vascular access, and respiratory. This list demonstrates the vast array of opportunities within nursing. The five parttime and casual participants split their working hours between two different areas. Further, participants had many years of experience in their current areas. The shortest time frame was two to three years. Four participants identified four to five years, while four stated six to nine years. Only one participant had worked in her current field for ten to eleven years. The participants identified factors influencing their decision to work in their current field of nursing. The survey listed ten different factors. All participants choose their current area of nursing due to the learning opportunities it provided for them. Seven of the nine participants identified a supportive environment as influencing their decision. Five participants choose patient complexity as an influencing factor. Other contributing factors included the working hours, location, previous positive experiences, personal relationships, indirect impact on family, excitement about the area, and the constant change. One participant added the additional factor of benefits/job stability. Even though nursing is a complex career, each nurse agreed that his or her choice of the current area of practice was influenced because of the potential learning opportunities. Each participant was experienced and enjoyed the learning aspect of nursing. Del Rio Torres 35 Nursing is not a solitary practice but involves interacting with many different health professionals. Each participant worked with other RNs. Four of the nine participants identified having LPNs as colleagues. The participants identified health professionals they regularly worked with as including managers; physicians; social workers; pharmacists; clinical nurse educators; unit clerks; care aides; physical therapists; dieticians; and speech language pathologists. Five of the participants also included working with occupational therapists, and three of the participants mentioned working with nurse practitioners. Five new categories were added due to the speciality areas of some participants: music therapist; respiratory therapist; dialysis technician; biomedical technician; and spiritual caregiver. Another aspect of the complexity of nursing in an acute setting is the diversity of health professionals. Positive and Negative Factors. The survey asked the participants to identify both positive and negative factors that they observed in their work environments. The participants experienced many positive aspects of nursing. The participants were offered ten options and one individual added an additional comment. Each participant observed teamwork, purposefulness, and the knowledge that they had made a difference. Eight of the nine participants observed a supportive environment, kindness, outstanding care to patients, and positive patient outcomes. Five of the participants identified a welcoming culture and an involved manager. Four participants experienced peace in their practice. Being genuinely thanked or appreciated for their contributions was the additional factor. Each participant faced multiple challenges. All of the participants identified the following negative factors: short staffing and caring for/dealing with physically and verbally aggressive patients, as well as changes in the participants' emotional or mental health, whether short or long term, related to nursing. Eight of the nine participants experienced a culture that accepted Del Rio Torres 36 violence as a part of the job. Seven of the nine participants identified the phenomenon of "nurses eating their young" and of relational aggression (horizontal or lateral violence, bullying, or harassment). Five participants experienced secondary trauma and changes in physical health, whether short or long term. Eight of the nine participants experienced a positive public opinion of nursing compared to five participants who experienced a negative public opinion of nursing. The participants faced positive and negative aspects in their nursing career. Finally, the participants were asked to identify self care practices. Twelve different options were offered. All participants identified friends as a part of their self care. Eight of the nine participants included rest/sleep and family time, while seven participants valued healthy eating and vacations. Other categories included exercise, pets, nature, hobbies, prayer/mediating, massage, and counselling. The survey gathered a wealth of information from each participant, providing a foundation for the data analysis. In Depth Semi-Structured Interviews The next stage of data collection was a semi-structured interview consisting of a set of guiding questions asked of each participant (Appendix D). Each participant chose the location of their interview; some interviews were in coffee shops and other interviews were in the individual's house, ensuring the participants felt comfortable in their chosen environment and establishing confidentiality according to the Research Ethics board [REB] proposal. Participants were encouraged to speak openly and share stories in their own words to ensure all the required information was gathered (Polit & Beck, 2012). Participant H shared how her experience helping a young woman who had chosen holistic treatments in lieu of medical treatment for her breast cancer made her advocate for her patients to be able to make informed Del Rio Torres 37 decisions. Participant D worked in hemodialysis, where the patients come week after week for years, she shared how her department kept a little notebook of events or details of their patients, so everyone could stay updated. The interview followed the "Four-D's" of Appreciative Inquiry (Magruder Watkins & Cooperrider, 2000). The purpose of the first "D", "discover" asks, "what is life-giving" or "what is most positive?" To discover encourages the appreciative aspect of what is present in an environment. The second "D", "dream", may also be considered "imagine" and asks the question "what might be?" In this section, the participants were encouraged to consider what would enable an individual to be resilient in strenuous times. Even though the participants were encouraged to consider answering this section as if no roadblocks existed, they still found it challenging to come up with concrete answers. The third "D", "determine" asks "what should be?" The study calls this section "design". After dreaming during the second phase, the participants were encouraged to think more practically of what should be or what would be considered ideal. For example, in the dream phase, one participant said she wanted to light the current charting format on fire and start over; however, moving forward to the determine section, she was encouraged to consider what should be. The final "D", "deliver" also known as "create", asks "what will be" or "what could be?" After each participant considered discover, dream and design, they were challenged to pull from their own experiences and consider what could be delivered and be sustainable to develop knowledge about resilience and the ability to nurture the personal growth of resilience in order to foster an ability to flourish (Richardson, 2015). Field Notes Field notes, another form of data collection that involves unstructured observations and interpretations, were completed after the interviews. Field notes are both descriptive and Del Rio Torres 38 reflective. Descriptive field notes include objective descriptions of what happened. Reflective field notes record the researcher's personal reflections, observations and experiences. Field notes provide additional information beneficial to data compilation and to understanding the data (Polit & Beck, 2012). Often, I recorded the field notes on my drive home after the interview, giving me time to process the interview and my observations. Two essential findings emerged throughout the field notes; these are integrated into Chapter Four. Here they are summarized briefly to illustrate the type of information included in the field notes. First, each participant mentioned trying different units within nursing in order to prevent burn out or becoming tired of a unit. This theme continued to stand out in the field notes because each participant mentioned it. One participant shared that over a four-year window they had only worked two and a half years in emergency; the rest of the time they were trying different areas because they needed a change and was tired of their current unit. Another participant mentioned moving to another unit to prevent becoming bitter and cynical. One participant mentioned a mentor who encouraged her to try another unit, and one other participant mentioned that her husband advocated for a change in her work area of nursing. Whether or not a participant was able to identify burn out or exhaustion at the time of change, they moved to another area of nursing. The second common theme among the field notes relates to the demographics of the participants. Three women with young families all mentioned their struggle to prioritize their family over their career, a decision which resulted in a change or decrease in their working practice. Because of the demanding nature of nursing one participant was in the process of deciding whether to temporarily stop working or to continue working very casually in order to give priority to her family. After I had completed all of the interviews and checked the Del Rio Torres 39 manuscripts, being able to return to the documented field notes provided nuggets of information that contributed to the data analysis. Reflexivity "Reflexivity is the process of reflecting critically on the self and of analyzing and making note of personal values that could affect data collection and interpretation" (Polit & Beck, 2012, p. 179). As the researcher, I was well aware of my own biases and frequently discussed my concern with my supervisor. During the interview process, as difficult as it was to remain silent, it was essential to allow the participants to share their stories and experiences without influencing them by expressing my own thoughts and experiences. One of the exercises I completed in order to reduce bias was voluminous journaling that discussed some of the concepts beginning to develop, allowing me to process some of the ideas. I did not want my own values or personal experiences influencing the data, even though at times I felt like I could relate to the participant. Data Management Data management is challenging but necessary in qualitative research to ensure the study is successful. Responsible management of the data consists of maintaining an organized system and the confidentiality of the participants (Polit & Beck, 2012). During the interviews, I used a recording device and immediately transferred the data to my personal laptop. I used a clear file naming system, so files were secure. Instead of labelling the documents with the participant's name, each participant was assigned a letter and all of their documents were labelled to maintain confidentiality. The information from the surveys was compiled into one document in preparation for data analysis. Some of the interviews were transcribed by a transcriptionist, others by the researcher. The transcriptionist signed a confidentiality agreement prior to Del Rio Torres 40 receiving any data. Each recording was labelled with the appropriate letter. Once the thesis is completed, all hard copies will be shredded. The documents will be scanned and saved for seven years on a password protected electronic device as per REB protocol. Data Analysis "The purpose of data analysis is to organize, provide structure to, and elicit meaning from data" (Polit & Beck, 2012, p. 556). There are several components of data analysis. After the interviews are transcribed, the researcher begins identifying categories that emerge from analysis of the interviews. After reviewing the categories, the researcher starts to develop codes and places the data into the correct codes. Creating Categories In the first stages of reviewing the transcripts, I highlighted different categories and potential themes. Given the large amount of information generated by the interviews, I realized an important part of my data analysis was to reduce the data to manageable units for reviewing. I decided to make four different documents, breaking down the content of each interview into the "Four-D's'". Thus, when reviewing the data, I was comparing all of the data from each question. Important concepts emerged and were categorized and recorded under the applicable "D". In preparation for coding, the concepts were compared across the "Four-D's" to check relevance throughout the entirety of the data. Topic Coding After reviewing all of the common themes in the four different sections, I began the process of coding. I started grouping common ideas into one theme. While reviewing the data, I continued with this process. Once I had several themes, after a discussion with Dr. Faith Richardson, I created a brochure to send out to the participants. The participants did not provide Del Rio Torres 41 feedback that could help me reconsider the data. I returned to the data and continued reviewing. In discussion with my supervisor, six different sub-themes were initiated, and the model of resilience/flourishing was created. Ensuring Credibility, Dependability, Confirmability, and Transferability Polit and Beck reviewed Lincoln and Guba's framework of quality criteria to ensure trustworthiness and rigour of research. They recommend using four criteria: credibility, dependability, confirmability and transferability. First, "Credibility refers to confidence in the truth of the data and interpretations of them" (Polit & Beck, 2012, p. 585). My research demonstrates the believability of my findings through evidence from participants' personal stories and experiences in the form of direct quotes from my interviews with them. The sincerity and candidness of the participants' experiences are demonstrated throughout Chapter Four. Second, dependability is the reliability of the data over time. This is demonstrated in my thesis through continuous review of the original data to create the codes and complete the data analysis. Third, confirmability refers to the data's accuracy and relevance when reviewed by more than one person. After the transcriptionist completed the transcribed interview, I reviewed each interview to ensure the accuracy of the transcript. The coding and analysis were completed carefully by only one person to ensure that the participants' voice were heard and that personal biases did not influence the analysis process. Finally, transferability means that the findings can be applicable to other settings. Resilience is not only a beneficial characteristic for nurses but for all people facing adversity. When nurses are able to flourish they are able to not only rise above but also change their experiences for the better; thus, one could argue that the ability to flourish is beneficial for all people. This applicability satisfies the requirements of rigour. Del Rio Torres 42 Ethical Considerations It is imperative when planning qualitative research to consider ethical implications in order to protect the participants from any harm. Throughout the duration of the study, the researcher must remain vigilant in case any unforeseen ethical dilemmas arise. My study was thoroughly considered and designed to ensure the applicability of the research, ensuring the participants' time was respected. Prior to any research involving participants, an application was prepared for the Trinity Western University Research Ethics Board. As the researcher, I was aware of the potential psychological and emotional risks to participants, due to the personal and sensitive information they might share about their nursing career. Empathy, validation and active listening skills were used as appropriate during each interview in order to protect the participant. After the interview, each participant received a one-page list of immediately accessible follow up supports and resources. Finally, after the interview, a follow up phone call or email was completed to ensure the participants' well-being and to ensure no outstanding comments or questions remained. Throughout all of the research, ethical implications were considered and respected in order to protect the participants and the study. Chapter Summary This chapter discusses the research design, methodology and procedure of this vital research. Instead of focusing on some of the negative aspects of nursing, Appreciative Inquiry focuses on what is currently successful and builds on that success through the process of questions to generate an ability to see new possibilities. Although I faced some challenges during the recruitment phase, nine participants volunteered to participate. Data was compiled appropriately to protect confidentiality and to allow the process of data analysis. Appreciative Inquiry was incorporated through the entire process of the interviews and participants' Del Rio Torres 43 experiences were protected through careful data analysis. The validity of participants' personal stories and experiences was also maintained throughout the research process as demonstrated through the rich stories shared in Chapter Four. Del Rio Torres 44 CHAPTER FOUR: FINDINGS This chapter discusses the rich data gleaned from the personal stories and experiences the participants shared during the interviews. Careful consideration was taken during the data analysis to discover how the participants viewed resilience and flourishing in their nursing careers. Using the data the interviews provided, a pictorial diagram was created portraying the development of resilience as well as the concept of flourishing. Model of Resilience and Flourishing The pictorial diagram is a visual demonstration of how resilience and flourishing are developed (Appendix E). The dynamic nature of resilience is represented by the exploding orange star. Orange is a combination of the colours red, representing fire, and yellow, representing sunshine. In heraldry, orange represents strength and endurance: resilience requires strength and endurance. Through the data, resilience was shown to be developed through the six sub-themes of personal life, intrinsic characteristics, sense of purpose/calling, education and career opportunities, workplace culture and reflection and self-awareness. While the majority of the participants did not directly define resilience, their personal resilience was evident through their stories and experiences. For example, participant I stated, "I think you can teach yourself [resilience], but it's an individual thing. Like I feel like in life I am very resilient and I can bounce easy; I'm able to leave it there and now I'm moving here, and I can switch it off in my mind." This comment demonstrates adaptability and an ability to bounce back through adversity. Participant D stated, "I mean in order to develop resilience you have to struggle." Resilience is not an intrinsic trait but emerges from experience and adversities that develop and strengthen the individual. The participants' personal stories demonstrated resilience, along with their love for nursing. Del Rio Torres 45 Personal Life Five of the sub-themes are represented by green ovals that symbolize the dynamic nature of growth and hope; growth and learning can provide healing and hope for the individual, resulting in resilience. Personal life is the first sub-theme on the pictorial diagram with three points. Throughout their interviews, each participant spoke of having a life outside of work. Participant A bluntly stated, "I leave work at work." Similarly, Participant G stated, ""When you're the nurse you just have to go; I've done everything I possibly can; the rest is now in the next person's hands and in God's hands, so you just have to really learn to disconnect yourself." Participant F also shared her thoughts on this issue: ...but honestly I had to learn how to not take it home with me all the time. I had to learn to rely on my coworkers, to vent. I had to learn to accept help when I was drowning, I had to, it really is a lot of separating work from home. It's a huge thing, and finding things that you enjoy, and doing them so that you can remember that you have a life outside of work. The participants valued their personal life thus keeping their work separate to maintain their own identities. This idea of separating work from home resonated among seven of the participants. The data revealed three different areas influencing the participants' personal life: self care; faith; and family first. Self Care Each participant spoke of building self care through different outlets. Some activities the participants took part in included having a network of friends and family, massage, exercise, healthy eating, faith, and church. Participant C shared: Del Rio Torres 46 I just started lately going for massages, as sort of treat for me for the hard work I do physically and emotionally. I take that as my me time, and just little things like that. It's ok to go out and sit with friends and have a coffee; you don’t always have to be go, go, go. Self care includes slowing down and taking care of oneself. Likewise, Participant G shared, I think a huge resilience is just taking the time to breathe; if you do need a sick day, actually take it, like don't go into work when you are burned out and toast and have nothing left for you because it's not fair. It's not fair for you or for the patients or anyone. Similarly, Participant A stated "You have to keep yourself healthy, and caring for yourself is one of the big ones." These individuals all recognized the need for self care, something that requires intentionality. Self care was an essential aspect in maintaining a healthy personal life. Faith Three of the participants spoke of the importance of their faith. Participant B spoke several times of her faith during the interview, stating, "I think my faith and church, I think, would be grounded in my purpose for why I am caring for people." Faith was a valued aspect of her life. Similarly, Participant E stated, "Well, my faith is huge, because I am a Christian and I like to, well that definitely helps with the caring component of nursing and will always drive me no matter what I face at work." In addition Participant G shared, "And God, he just lifts me through the whole thing, so he's a big big part of it all." These three participants shared finding strength and encouragement in their faith, thus nurturing their resilience. Family First Five of the participants spoke of prioritizing their family. Participant G stated, "...because you do need to put your family first." Her family was more significant than her work. Participant C stated, "Spending time, or making time to spend with my family in the evenings, no Del Rio Torres 47 computer time, no cell phone time, whether we're watching TV or sitting out on the deck together, things like that." In order to put family first, this participant intentionally prioritized her family. Several of the participants spoke of having to arrange childcare so they could work. Participant E spoke of only working casually so she could tend to the needs of her family at this time in her life. She stated, "Because my intention is to be as much of a stay-at-home mom as I can while my kids are young." In addition, Participant H spoke of her extended family: In terms of home, just like I obviously have my partner, and I have quite a bit of family around as well. So in terms of managing my home life which allows me to go to work and just do what I do. Because if I need babysitting, that sort of things, in terms of support that way I have lots of people around. So a good network with people. An aspect of the personal life that the participants valued was their family. They made an intentional decision to prioritize family; the decision enabled their resilience. Family Challenges. An important idea that resonated throughout the data was whether family and friends could truly understand the realities of nursing. Five participants found appreciative understanding from people who were nurses or in a caring career. Participant B shared, "I'm fortunate to be married to a nurse, so he's a little more understanding of my job which makes it go easier on the family." Participant F stated, Well, I have good support in and outside; most of my good friends are nurses, or are involved in a profession that involves a caring capacity, be it teaching, or nursing. They understand, and even if they’re just there to listen, it helps. My husband, he just laughed. He’s not very good at listening to that sort of thing because he works for [healthcare Del Rio Torres 48 management]. So, he gets it, but doesn’t get it, because he’s much better at leaving work at work than I am, but the thing is he is not as emotionally involved as I am. Even though her husband works in a health-related job, he lacks awareness of the depths of nursing. Participant C shared, So my family is a big support; my daughter is in her fourth year of the RN program, and her and I get to chat nurse a lot, and I think that helps too with just talking about how things go, or have gone, because my husband doesn’t want to hear about it. Participant D stated, I would say that, to some extent, for me [nursing] has always put a bit of a drain on my family and social life. If nothing else, just based on the fact that most of my friends who aren’t in nursing are not dealing with the kind of situations I am on a day-to-day basis. Likewise, Participant H declared, ...because you can come home and tell your significant other about the generalities, like I had this patient, a real hard scenario today whatever, but they don't get it. It's not the same to vent at home. Because you can't explain all the details and even if you did, they can't understand the details for the most part of what it's like: it's only for nursing people, or friends, like work, co-workers, like if you're in the moment with that patient, if like a code situation happens, it's like, you know, you get it. The participants' stories and experiences reveal their difficulties in sharing the daily complications of nursing with those who are not personally involved in nursing, as they simply do not understand. Regardless of their family's inability to understand, however, the participants highly valued their family as an aspect of their personal life. Del Rio Torres 49 All of the participants spoke of the significance of their personal life apart from their nursing. Their personal life included self care, faith, and putting family first. Several participants shared the challenge of their family not understanding the complexities of their career. Regardless, the participants' personal lives contributed to their growth and hope, developing their resilience. Sense of Purpose/Calling A sense of purpose/calling is the second sub-theme on the pictorial diagram. The Oxford Living Dictionary defines purpose as "the reason for which something is done or created or for which something exists" ("Purpose", n.d.). Beyond Blue, an Australian mental health resource, defines a sense of purpose as "the motivation that drives you toward a satisfying future. It also helps you to get the most from things you do and achieve" (Beyond Blue Australia, 2016). A sense of purpose helps an individual prioritize his or her life. The Merriam-Webster Dictionary defines calling as "a strong inner impulse toward a particular course of action..." which may include a divine influence ("Calling", 2017). Although these two concepts are different, in this research they are viewed interchangeably. Each participant demonstrated a sense of purpose or a calling throughout the interviews, either directly or indirectly. Source Three of the nine participants directly spoke of a divine influence on their nursing career. Participant G stated, "I think the fact that I felt called by God. So I know that no matter what, when I go back, he will give me whatever I need to get through it." Her faith is a source of strength during adversity. Participant B stated, "I think, [viewing nursing] as a vocation and calling rather than a job." She later indirectly talked about the impact of her calling: Del Rio Torres 50 ...but [I] also have the ability to change people by seeing people where they’re at and seeing them for who they are, and in my personal opinion, how God sees them, and seeing them, and caring for them in a way maybe nobody has before. As previously shared, Participant E discussed the significance of her faith influencing her ability to nurse. The source of these three nurses sense of purpose or calling is found in their faith in God. Expression Six participants did not directly mention sense of purpose/calling; however, they demonstrated it throughout their interviews. Seven of the participants directly spoke of wanting to a make a difference. Participant A stated, "I do want to make a difference, and I do want to help people." Similarly, Participant E stated, "...to make a difference, to get out of my smaller world and to make a difference, outside of my own family." Her desire is to make a difference beyond herself. In addition, Participant F stated, "I mean I do enjoy helping people, I enjoy seeing people get better, I enjoy, as sick as it sounds, helping people have a good death." The participants' desire to make a difference demonstrated their sense of purpose/calling. Several of the participants shared stories of experiences where they were able to make a difference in an individual's life. Participant D tearfully talked about one experience that demonstrated her selflessness and desire to make a difference: When the patient feels understood, you know when you have patients who are going on dialysis, it’s generally not safe to get [them] up. We would prefer [the patient] would use a bedpan as opposed to [the patient] getting up and getting on a commode or being taken off the machine and going to the washroom… and you know we had one lovely patient, who although she was very frail and very unsteady, it meant so much to her to not have to sit in Del Rio Torres 51 a dirty brief, and she knew that I would always be the person that would come and let her use the commode, and shortly before her death she fractured her femur very badly, and it was less than secured. And her bowel problems were related to a medical error that had happened to her when she was younger, and her bowels, of course were going and everybody just kept saying to her, you know we’ll just clean you up and roll you over after. She called to me and I spoke to her, and we knew, and with the three of us, we were able to get a bedpan under her with her broken leg, and there she is with her broken femur, on the bedpan, holding my hand, and just saying thank you. You know here she was with her broken leg but it meant so much more to her. Even though her response to the patient required extra work, Participant D demonstrated her desire to make a difference, exemplifying an aspect of her purpose and calling. Participant G shared a common occurrence that has established her calling in her profession; she often works with individuals with dementia or Alzheimer's whose disease has altered their personalities. She stated, I've had family members come up and apologize for the way their family member has acted, and I'll say [to the family] from what I know, this isn't them. I've seen pictures, I've heard stories, I know this isn't them. I hold nothing against them, I hold no grudges; they're in here because they're sick. She is able to see beyond her patients' diagnosis and remember that behaviour does not identify the patient. This participant's sense of purpose/calling is evident through her desire to make a difference. Del Rio Torres 52 Outcome Whether a sense of purpose/calling has knowingly or unknowingly shaped each participant, they have each demonstrated a selfless calling to make a difference in their nursing careers. Participant C shared an experience that reveals her sense of purpose/calling: I go to hospice and my cup gets filled up just from being around the patients and the gifts that the family give to you, that a lot of other people aren’t privileged to; it’s just an honor, to share in those stories and be a part of that journey that it just, fills my cup up... She becomes reenergized because she is working within her sense of purpose/calling. Participant I also shared her sense of purpose being fulfilled: "As a PCC, I feel like when I can get patients' care planning and getting them home, which is my goal and help decongest our emerg. I feel I make a difference. That's why I keep going back." Working within this sense of purpose/calling is positive and encouraging, thus contributing to participants' growth and hope and fostering their resilience. Intrinsic Characteristics The third sub-theme on the pictorial diagram is intrinsic characteristics. The Cambridge Dictionary defines "intrinsic" as "being an extremely important and basic characteristic of a person or thing" (Intrinsic, 2017). Throughout the interviews, the participants demonstrated their own intrinsic characteristics: their positivity; their dedicated and unrelenting spirit; and their caring nature. Thus, the individual's personal traits assist in his or her development of resilience. Positivity Each participant spoke of and demonstrated the personal positivity, an intrinsic characteristic that influenced their outlook and consequently nurtured their resilience. Participant A stated, "I am generally a positive person. I try to think the best of every situation. That Del Rio Torres 53 personally helps me to not bring any baggage home; ...even if it is a negative, I try and turn it into a positive." Similarly, Participant I shared, I think when people see you coming, and coming in with a positive attitude, seeing that you're not bringing yesterday's drama to today, or yesterday's things that were kind of terrible to today or taking those and spinning it to a positive way. So you know, that code was terrible and I can't believe that we didn't have this and that in place, but, hey, guess what for tomorrow, or today, it happened yesterday; we're going to move forward and this is what we're going to do for the next time so it does happen. So I think if you can try and just be the optimist or try things around into a positive light, it influences who you're with. Instead of choosing to be pessimistic. Participant C chose positivity. She shared about her ability to pass on her positivity to her patients during their challenges. She stated, "... just reminding people that, “hey, you’re still here, you’re still now, and there’s still good stuff happening, and to embrace that, and hold that.” Positivity influences people in the surrounding area. Participant G stated, "You scream at someone or get mad at someone, and everybody gets frustrated by the end of the day; you smile, most of the time at least 80% of people are happy at the end of the day." Participant D shared a key example of positivity during a challenging experience: ...in the last few months there has been some management changes, and other things have gone on that have made that more difficult. I would more speak from the history of the unit than the current space. I think the current situation is more of a speed bump as opposed to a cultural change. Each participant exemplified his or her intrinsic positivity, a characteristic that enabled their resilience to grow as well as positively influencing those around them. Del Rio Torres 54 Dedicated and Unrelenting Spirit The second intrinsic characteristic the participants demonstrated was their dedicated and unrelenting spirit; this included being driven, stubborn, adaptable, and determined, as well as having a good work ethic. All of the participants identified their strength and their desire to work hard. Two participants shared their personal experiences of working with difficult patients. Participant G stated, "Or that patient that is really difficult and you're like I'm going to break you, and like make you feel better and help you get out of this dump." Likewise, Participant H shared, Even when you have people who are kind of aggressive, I usually can talk people down, so it makes dealing with [the] public and some interesting personalities easier because I can relate to them or find some sort of way to relate to them. These two experiences demonstrated these individuals' determination when working with difficult patients. Instead of choosing to walk away from an unpleasant situation, they chose to work with the difficult patient to find a positive outcome. Participant D's strong will and determination also benefitted her colleagues and department. She stated, ...last year, I was in charge and we had a very traumatic code with a young person who did not survive, and I made a very concerted effort to get critical incident debriefing for my staff, and when there was hesitation to that, I caused enough of a ruckus that the staff have agreed that at every staff meeting now we’re actually going to take some time to talk about any of the incidents or deaths or losses that happened in the last month for us on our unit, and so I think there’s something to be said about being vocal. Her strong will and determination enabled her to advocate for her unit's well-being. Del Rio Torres 55 Participant F shared her heartbreaking experience as a new graduate. After a horrendous code blue where the patient passed away, she was cleaning up and overheard her colleagues making fun of her, which brought her to knees; she was devastated not only by the traumatic code but also by her colleagues' remarks: I’ve been lucky so far. I’ve had some really really crummy times as a new grad; it was horrible; I was going to quit nursing, and I fought through it, and I didn’t get any support... I'm sad, and because of this job I've become a lot harder than I was, because you've got to have that shell, if you don't, you're going to get eaten alive. Through her determination she was able to rise above and overcome the difficult situation demonstrating her strong will and driven personality. Five of the nine participants demonstrated their work ethic by identifying their sense of responsibility to show up to work. Participant B stated, "...probably some sense of responsibility of work..." and "... to make sure that you're responsible to do the best to your ability as long as you are well." Two of the participants spoke of working short staffed because of sick calls and of not wanting to be the person who caused a shortage. Participant C stated, "I don’t want to let them down either [in regards to co-workers]; like the other day, we came off night shift and were down two nurses and a care aide … and I don’t want to be that person." Similarly, Participant H stated, "Just partly, you know, even if you're coming on shift it's going to be short staffed or your anticipating--you're wanting to go in to support the members..." In addition, Participant E simply stated, "Showing up to work." The five participants shared their strong work ethic and their commitment to their units. These nurses demonstrated how their dedicated and unrelenting spirit benefited their shared experiences benefiting their patients, patients' families, colleagues, and themselves. Del Rio Torres 56 Caring Each participant discussed the value of caring for the patient, even with the constant demands and high patient volumes. Participant F stated, Yeah, you need heart... the thing is that you can't teach somebody how to care, and if you don't have that, the most terrible nurses that I've ever seen, usually it's not because they... most of them get all their stuff done, but they haven't spent any time with their patients; you need to care. Several of the participants specified how caring is natural for them. Participant I stated, "I feel like it's just who I've always been. It took me a while to figure it out, that's what I want to do. Just my caring side, that comes naturally, I feel." Similarly, Participant F stated, "I care about people." In addition, Participant B shared, "To be able to really care for people while in those critical crisis situations, like that gives me life that we're able to like deal with people in crisis well and support them well." As well, Participant G stated, "I think that's a big one, just kind of seeing people as a person not a diagnosis; not a situation but as an actual person." The participants shared how their genuine caring for the patient during an acute crisis positively influences the patient. The participants gave examples of truly caring for their patients. Participant C stated, And then they're [patients are] saying, "oh you're so busy; you've got this x number of patients", and you're saying, "no I'm here, I want to be with you." To let them know that it's okay to cry, or feel horrible, or be mad about the system, and just to be there for them. If you don’t have that love, I don’t think you can give that to them. Caring promotes a holistic approach. Participant E worked in an Intensive Care Unit where often the patient is comatose. In the interview she shared how she talks to these patients, even though Del Rio Torres 57 she is not sure they can hear her: "But it doesn't stop me necessarily, because if they did hear me, well they might like it." Participant C shared how genuinely caring for a patient is rewarding: The connections with the patients we make, even if they're only the patient overnight--it's just really so rewarding to be there, even if it's just taking five minutes sitting on the edge of the be: "I hear you got some rough news today, do you want to talk, or do you just want to sit," and just giving them that presence of you being there. Caring is an intrinsic characteristic that creates positive experiences for the patient, the family, and the nurse. Some of the examples speak of the nurses' ability to go above and beyond the requirements for a nurse to demonstrate a genuine care for the individual. Participant F stated, My first clinical experience was palliative care over at Eagle Ridge, and that made me appreciate; palliative care to me is true patient centered care. You want to have a bath at 3 o'clock in the morning, fine, let's have a bath. And I try to keep some of that in mind with anybody, that it's not about me and yeah it might inconvenience me, but I'm not the one in the bed. So what can I do to make this a little less sucky for them. Participant F was reminded of an experience of genuine caring during her clinical experience that influenced her practice. In addition, Participant C stated, We’ve got a gentleman on the oncology unit right now, and he still does his papers for MAID, which is the medical assistance in dying. Umm, and he’s like yeah well I’m dying, I’m done, and yet he turns around and tells me these jokes and I reiterate it back to him, like you have so much going on, like I don’t understand his reasoning, but then it’s his decision of course. Just letting him know that you know [that] those jokes and the stories Del Rio Torres 58 you are telling me, those are valuable, those are important… like you are not a waste, like he seems to think he is. Through her caring spirit, Participant C reminded her patient of his personal value. Participant D worked on a dialysis unit that as a whole advocated for their patient's situation: We have an overnight dialysis program that’s got very stringent criteria in order to get into it, and we’re currently at the moment going outside of those criteria knowingly, in order to give a relatively young man more time with his family after he has been diagnosed with terminal cancer…. And so we all know we are kind of going outside of what we would normally put in the program…: … but we know we are doing it for that nursing kind of reason, and so everybody is on board. Their caring spirits enabled the young man to have more time with his family. She also mentioned, "...it is the kind of unit where you will sometimes see nurses going to funerals of patients…" This type of response is above and beyond all nursing responsibility. When a patient enters the hospital in a health crisis, a caring nurse contributes to his or her health and healing. Each participant shared the importance and value of the intrinsic characteristics of positivity, of a dedicated and unrelenting spirit and of caring. These dynamic characteristics contributed to the development of their resilience. Education and Career Opportunities Education and career opportunities comprise the fourth sub-theme on the pictorial diagram. The participants' data presented three aspects of education and career opportunities: education advocacy, lessons learned, and opportunities in nursing. All of the participants demonstrated not only their love of nursing but their desire to continually learn and be challenged. Participant B Del Rio Torres 59 was direct in stating, "I think I am a person who really loves learning; I love doing something that I feel really confident at, and actually keep coming back and wanting to learn more and challenge myself and experience different things." In addition, Participant E shared, "...the learning has kept me interested in nursing." Similarly, Participant F stated, I enjoy the learning part of it, because there’s always something new to learn every day, and if you’re not learning, you’re not doing your job. Whatever it is, whether a new med, a new diagnosis, a new fun fact that isn’t necessarily related to much to do with your patient per se, but it could be new wound care thing, whatever pick something, but I like the learning aspect of it. The participants spoke of their desire to learn and be challenged in their nursing. Education Advocacy The participants not only loved the learning involved in nursing, five of the nine participants spoke of the value of education and learning. Participant E stated, I always think the education is huge, to also keep you involved and engaged in nursing. So that way having education days and you know having a focus on education. Even the time, because we'll do lots of in-services, but you may not necessarily have time on your shift to go to the in-service, so if they actually make the effort to have some coverage or find a way to make it easier. Participant H similarly advocated for education: ...[it] would be nice education wise, [if] they would offer more education opportunities for staff. There's [education] that come up, but to try and get a day off, and get paid for certain education, the funds are very limited; it's kind of well we'll pay you for 7 hours of your 1 day of 2 or 3 days of education, like it's not there. ...It would be nice if they had an Del Rio Torres 60 education week or you know, where every year you got to go and do your CPR and everything you needed in that week and you were just paid like the RCMP does this for our staff. That would be ideal. That would be a dream. Because then everybody would be on the same page and they'd be updated every so often. Participant H values different educational opportunities and being able to attend or easily access them. In addition, Participant A stated, "...proper training of staff because when other staff do not have the proper training it is stressful for the persons without the proper training, and also for the people working with them, and it's not so good for the patient." The participants loved and valued education but also shared the understanding that all nurses should participate in education to maintain their practice standards. Two of the participants spoke of resources beneficial for personal education and growth. Participant C stated, ...the union has put on a course, this is from BCNU, and they put on a trauma workshop, to help with secondary trauma; it's a day long workshop, and it’s the best workshop I’ve ever been to. They had a retired police officer, and so he was able to connect really well to primary and secondary trauma, and it was an amazing workshop. Participant I discussed a resource available through her health authority for all its employees: I know we have the Critical Incident Stress Management, and I found to be a part of several debriefs of different things, and I found it to actually be quite helpful and not just one on one but as a group and to be offered at the time and support and have that facilitated right away. That you can, or later if needed. If you need time because of what's happened, not being put on APB because of it. Or being questioned for it but more of how can we help you to get back or to feel better, that sort of thing. So I think just an understanding of a lot of the PTSD, you know our staff do face, that would be important. Del Rio Torres 61 These participants not only valued the ability to continually learn in their nursing career but they advocated for education to be promoted and accessible to all nurses, to increase their engagement. Lessons Learned In the interview, each nurse was asked to consider what stood out from their initial nursing education, their continuing education, and their conversations with others as bringing life to their nursing. Fascinatingly, some of these experiences occurred years ago, but the nurses shared them in clear detail. For example, Participant H shared, We went to a patient's home, and I was never really comfortable with community nursing, like going into people's homes. We went to this guy's home, he lived out by some railroad tracks in this dilapidated old house, that literally when you went in it, it was... one part of the house was completely, like not a hoarder just kind of filled with stuff and then he had this little tiny kitchen, he didn't have any running water, and he didn't have any hot water, like he would go and fill, I don't know if had a well or something, he would go and fill the bucket and he would go and heat up water on his stove to basically wash himself. And he was quite clean himself, and he was very meticulous when we were teaching him his colostomy care. And I remember my instructor saying, "remember when you send people home from the hospital this might be what they're going to, so you need to do your teaching, and you need to recognize that there is barriers to people when they go home." Like you don't know what they're going home to. This experience positively shaped Participant H's discharge teaching for her patients. Participant D also shared her experiences: Del Rio Torres 62 I would say, for me at least, from my education it was always the times in practice, as opposed to the times in classroom that I developed that from. You know, I’ve certainly gone to nursing conferences and come back with new information, and been excited about putting new techniques or information into practice. But to me that’s more the science part of nursing. You know, for me it hasn’t necessarily been so much any sort of structured education but my time in the workplace and my time with the patients. For some, influential learning occurs on the floor with hands-on experiences. Not every experience directly impacts the patient. Participant B stated, Just conversations with older nurses that have been in it a bit longer, that have kind of mentored me, have kind of just, you know, in the middle of a situation, kind of pull[ed] me back and given me a view of what's really going on, and kind of reminded me of why we are in this and what really matters. These stories are examples of how the participants valued the lessons learned from the beginning of their education onwards throughout their careers that have impacted their current practice. Opportunities in Nursing The participants shared how they enjoyed the different opportunities within nursing that encouraged their continual learning and their desire to be challenged. Five of the participants specifically mentioned different opportunities within nursing. Participant E spoke of her experience at a job fair she attended as a new graduate: I remember going to a job fair right when you finish school, and you're very green. And one of the ladies at one of the booths was saying that to not get jaded, the best thing to do was to move around, to try all the areas, because that's the advantage of nursing, because there are so many areas, that you can find to suit wherever you are. Del Rio Torres 63 Because of the sound advice she received as a new grad, she stated, "I always moved around to different areas; it was almost as if when I was comfortable in an area, then I would move onto the next area." This process enabled her constant learning and filled her desire to be challenged. Similarly, Participant E shared, I did medical and decided to go travelling, so I did a year in Australia, and I came back and I didn't want to do medical again, so I tried surgical, and then I went travelling again on Mercy Ships. Came back and knew I couldn't stay in surgical and it was a bit of burnout there; I found that we were sending a lot of patients to ICU. And the opportunity came to take the ICU course, and I was like I'm taking it because I'm tired of not knowing what happens when they come out of surgery and also I felt like we were failing because we were sending patients up to ICU. I wanted to know what I could do to prevent that from happening. Because of experiencing multi-faceted aspect of nursing, she pursued an additional certification in nursing that enhanced her development. Another benefit of the multi-faceted aspects of nursing is being able to change departments when needed. Participant F needed a change from a negative environment; she shared, "I took a part-time float position, which I know sounds really strange because it’s like “what? You wanted to float willingly?”, because I wasn’t sure what I wanted to do." While she worked on different floors, she was challenged and able to see what aspects she valued in a positive working environment. From her growth and experience, she decided to work on a specific floor that she enjoyed. When asked if this area is her "new home," Participant F responded, "for now, I mean I’ll get bored, don’t get me wrong. It’s nice because it's new." Del Rio Torres 64 The participants valued their continual education and the multi-faceted opportunities their career offered them. This appreciation is evident through their love of education and desire to advocate for education, as well as through the lessons they have learned throughout their careers. The participants also spoke of the advantages of having a multitude of opportunities within nursing. Overall the participants' education and career opportunities contributed to their growth and hope, developing their resilience. Workplace Culture Workplace culture is the fifth sub-theme on the pictorial diagram. Throughout all four sections of the interview, each participant brought up workplace culture as influencing resilience. Some of the nurses shared negative experiences which eroded their resilience. In some situations, the individuals left the negative area in search of a positive workplace culture. Every participant shared positive experiences and aspects that contributed to a positive workplace culture: teamwork; a safe environment; and an involved management team. Teamwork Each participant shared the value of teamwork and the relationships built within the unit. Participant E stated, "And then work, itself the environment, it would probably be who I work with. Teamwork and the morale you could say also helps." Similarly, Participant A shared, "Well, having good support group at work." Throughout each interview, teamwork and colleagues were continually brought up. Participant H stated, "From work again, it would be my work colleagues." In addition, Participant B shared, I think inside of work, just being in a culture of nurses that also have the drive to care for people. When you are working with people who work really hard that also drives you. Having the resources at your fingertips, having that support of other members of the health Del Rio Torres 65 care team that you can all work together to do what's best for the patient and you're not alone. Teamwork is easily cultivated when similar values are shared. Participant D shared, "But there is that real kind of sense that when you’re around other people in your practice who enjoy what they do, or are passionate about the outcome." Participant H shared an advantage of teamwork: "Yeah, basically just working with them, because if you're in trouble, the patient, something is going, you're just calling for help, and they're your backup." A unit's culture is positively influenced when there is teamwork and comradery between colleagues. Similarly, Participant B shared, The first thing that comes to mind is the good sense of humor and the laughter that you have with all your co-workers. But I think I think just having a really supportive group of people that pulls together and works hard in the difficult moments but also be able to laugh at each other and care for each other. Teamwork is a really big part of our job and definitely keeps you from feeling totally drained, and un-important, and alone in your job, and the weight of that starts pulling on your family life. I think when it's shared among other people; it doesn’t drain your family life that much. A supportive environment spreads the burden of the shift, making things easier on everyone. Participant C shared, I think the team is important, because if you are all sort of struggling with that hard day, it's helpful to say to your co-worker, "I’m having a really hard time today," and they’re like, "yeah me too, why don’t you take an extra five minutes on your break," or something like that which does happen on our unit, which is nice. So, the support from your co-workers, Del Rio Torres 66 we don’t see it as much from management, but we do see it with our co-workers, the other nurses you’re with, because they're likely walking a similar path as you. In a healthy environment built on teamwork, co-workers look out for one another. Participant C shared a relevant experience: ...there was a new grad nurse on, and she came on as work load, which was great, and then she ended up taking on the assignments at 11:00, and she was just sort of thrown into it, and I felt so bad for her. So, she went and had her break, and she was getting ready to go lay down, and I went into the room where she was, and she was just sobbing her heart out. She felt like she was letting us down, and that she wasn’t a good nurse, and the mother part of me came out, because my daughter is in the nursing program. I sat with her, and put my arm around her, and just consoled her, and said, “you know what, it's a hectic night for everybody on the unit, I can’t imagine how you’re feeling, but know that it’s okay to feel overwhelmed, it's okay to cry, and that we’re here to help you, and we’re here to help you learn how to be a good nurse, cause you will be a good nurse, you’ve made it this far.” When I saw her on my next rotation, she came up to me and was like, "thank you so much for doing that," and I didn’t do anything, to me it was just what we do, I mean, you care, I don’t know how can turn off that caring part. Because of the positive environment, Participant C was able to look beyond herself and welcome a new person into the positive culture and to encourage the nurse in her brokenness, demonstrating teamwork. The participants gave many different examples and results of working with supportive colleagues to develop teamwork. Participant G shared, Del Rio Torres 67 I have a very encouraging floor and that's really nice. Um, we actually started this Thank you Thursday now. And they thank different members of all the different teams' they have little writeups for them, not just like a specific person, but like the cleaning staff, thank you for keeping our floor clean and I really love that. 'Thank you Thursday' exemplifies the positive dynamics that promote teamwork among colleagues. In addition, Participant H shared, I think that work, like often times on night shifts, we'll bring snacks or have potlucks and that sort of thing, you know to kind of get through the shift, but also if it turns out to be a crappy shift, you're in it together. Like you kind of sink or swim together right. Like if you're sinking, you're all sinking together (laughs) you may as well laugh about it because what else are you going to do about it. As well Participant C shared the benefits of teamwork and comradery: I think the connection with my co-workers, if it’s been a really hectic day, at the end of the day, it’s like why don’t we go out for a bite to eat after work, or next Thursday let’s get together for lunch… and a bunch of us will go out for lunch together. I have to say our unit is pretty good for things like that, and it's pretty nice. Each participant shared his or her experiences of teamwork and the benefits of a positive relationship between colleagues in developing a positive workplace culture. A Safe Environment During the interviews, six of the nine participants mentioned that working in a safe environment influenced their ability to be resilient. Participant B boldly stated, "I think just fostering a place that feels safe and that's encouraging." The different elements of a safe Del Rio Torres 68 environment that the participants discussed were safe staffing levels, adequate training, and proper rest times. Participant A stated, Well, maybe better staffing, just having the baseline at least and then with changes of needs, like having a one-to-one intubated patient, you need to know you need extra staff for that, just so we can give proper care. ...Also, proper training of staff because when other staff do not have the proper training it is stressful for the persons without the proper training, and also for the people working with them, and it's not so good for the patient. They should give proper rest time, like the breaks that are allotted. Lots of people miss breaks because of those two things not being met. ... I feel like if all those things are met with proper staffing, proper training, and proper workplace, I won’t be drained because there is nothing to drain me because it has all already been dealt with at the proper time. I wouldn't be drained at work. I feel like if we address one area, we will address the other area. He argues that if staffing and proper training were addressed, the resiliency of the nurses would allow them to persevere through the other challenges. Similarly, Participant E stated, I see that they're dealing with being short staffed for months now, and they've also gone through a bunch of managers and I've only had a small taste of it. But any time I come to work the morale is down because of this. Even resilient people struggle with working in an unstaffed environment. Participant B voiced a similar concern: I think when they just feel unsafe, whether from poor staffing levels, too many patients, or complication situations where they are not feeling competent, you know I think those sorts Del Rio Torres 69 of things really decrease flourishing really, really fast, and I think if we provide an environment that has experienced nurses, that they do feel supported and safe. In addition, Participant D stated, I think that even doing things like properly assigning your nurses to the best of your ability, and building your teams and building your schedules so that you have more experienced nurses with some of your less experienced nurses…. And allowing your assignments to work in the way so that you’re not overloading your new staff too soon. You’re allowing them time to build that resilience without being completely flustered at the beginning. Participant I shared a similar point: So if we can encourage our young people and ensure that they get their breaks--not young sorry, new to the profession, they are not necessarily young--and help them, answer their questions, give them an orientation, not just one day here and one night there, ok now go ahead, but actually supporting them, going through a CAPE tool, having proper mentors. Participant F shared the results of working in a safe environment: So there is a lot of support where I work. As you can tell I'm happy. I'm amazed at this place right now; there's a reason why people stay here for 15 years, because they know how good they have it. Like in this case the grass is greener on our side. The participants shared the elements of a safe and healthy environment as consisting of safe staffing levels, adequate education, and proper breaks. Leadership The third element identified by all of the participants as contributing to workplace culture is the leadership on the floor. This leadership includes charge nurses as well as management. Del Rio Torres 70 Each participant shared attributes they respected and appreciated from past and current leadership, and some shared attributes that they did not appreciate. Frontline Leadership. Four of the participants included their charge nurse (CNL/PCC) in the conversation. The participants wanted a charge nurse who was available, intervened when the nurses needed assistance, and advocated for their staff. Participant C shared a common discouraging experience on her unit: ...some mornings you come on at seven, and you see the board and you see we’re down a couple of nurses, and the CNL comes in and says, “oh yeah, we’re on it… we’re on it…," and they go to their office with their clipboards. I mean if they came down to where we were running around trying to do our one touch and vitals and getting everything done before breakfast, if they could say, "here let me do your one touches" or "here I'll take a patient from each of you and I'll go do their vitals" that would make a world of a difference…. And it would just show that they still get it. In contrast, Participant H shared a positive experience with her charge nurse: One of our acting PCC's, when our original one was off, was like, "ok, I'll come help you move the bed, let's move it, you know, you're busy." And so in terms of getting through a tough day when you're busy, and they're pushing, when they jump in and do those little things, it makes such a difference. Because it's like, ok, they realize that we're busy, so they're going to move that bed, or they're gonna, you know, put that IV in that just blew, and your antibiotics late because whatever and they're gonna jump in right. And it's like, the tiny things, it's not the big, like you're going to go do an assessment on a patient because I really need to assess that patient myself, but you're going to do the little things that take time, that you don't really have on a really busy day. Del Rio Torres 71 When a charge nurse steps onto the floor and assists their staff, the morale of the department improves. Participant F also shared a positive experience: I mean when we have extra vents on the floor we automatically get extra staff, when we’re really heavy, like today; the day before was a complete gong show with needy patients who were ringing insistently, for crap, they, just well it's not crap, they are anxious, they’re in pain, they’re nauseated, and it just spirals with a dependent personality and they just want you to sit there and hold your hand, and you can’t, and they want something for pain, you walk to the med cupboard, and you don’t even get a chance to pour the med before the ringing asking you for the pain medication again. It’s one of those things, so they brought my manager and my CNL okayed workload, so that we could have a nurse on the floor to help out, to prevent stuff like this. This example portrays how teamwork from both levels of management positively contributes to the department Participant G also shared her thoughts on this issue: I think more people, they need to screen their PCC's more, maybe that's what it is. Some PCC's are just, they're there because they can't bedside anymore, because they've been injured or something like that, and I think there's better places for them to go. Um, I know a lot who have done that because they have been injured at the bedside, and I feel, I totally understand what they're going through, well I like to think I do, but they're not set for the PCC, so just kind of doing a better PCC screening. And then also, making sure that the PCC does rotate, because I feel like when they're there for so long, they kind of lose that connection with the staff and they don't have that support anymore. So maybe have them rotate out, where they're back on the floor for 3 months to just get that idea again in their minds. Del Rio Torres 72 Successful leadership is able to collaborate to meet the needs of the unit, thus contributing to a positive culture. Manager. The participants not only spoke of characteristics they would like to see in a good charge nurse, they also identified characteristics distinguishing a good manager. According to them, a good manager has an open-door policy, works through problems as they arise, has effective communication skills, and is available to the staff. Participant A stated, Well, she has open-door policy, so I really like that, if you have an issue, you can talk to her. Usually she will actually deal with it in real time. She just doesn't brush it off. I feel like a manager that has an open-door policy like that and actually deals with the issues at that time is really good. Similarly, Participant F stated, ...my manager is pretty good for a manager, I mean her hands are tied and they can only do so much, they can’t fix things. Rules are rules, and they’re caught in the middle, and I recognize that, but the manager I have right now is pretty decent; she listens and does what she can, and I mean, she’s been fantastic with staffing levels... In addition, Participant B shared, I think being someone that is open and available if you have comments or concerns that you're able to bring them up, and that you feel heard and that action is at least attempted, and there’s communication about that, even if it can't be successful for a bunch of reasons, just that there’s openness and transparency with the process that was done to try to resolve the issue rather than feeling like you're not heard and nothing ever changes. I think transparency contributes hugely to employees' resilience. Del Rio Torres 73 Participant E compared two managers. One manager was on the floor and available. "And the next manager, I don't even remember her name or anything like that. She just wasn't there." When a manager does not embody these characteristics, the workplace culture deteriorates. Participant G shared the results of having a negative manager: I had the horrible manager, and we tried everything to get rid of her; she was actually previously a PCC on another floor...; they petitioned and got rid of her. And the way they got rid of her [was] by promoting her to medical management. Which is totally 100% inappropriate cause all that she did was take it down on us. And she destroyed the floor, like half of us left because of it; some nurses early retired because of it; it was just really bad. Participant C also shared a devastating experience: "...since January, we’ve had fourteen nurses leave our unit... Yeah, that has to do with management, and not getting the support that we need… that’s why they’re leaving… which sucks… it really does." The participants stories speak of the importance of a healthy workplace culture. The data demonstrated three key elements influencing this culture. First, each participant shared the importance of teamwork through thick and thin. Second, the participants spoke of the importance of working within a safe environment, and finally, of having an involved and aware leadership team on the unit. The participants shared their desire to work within a healthy workplace culture that enabled resilience. Reflection and Self-Awareness The sixth and final sub-theme on the pictorial diagram is reflection and self-awareness. It is visualized through two light blue arrows that demonstrate this continuous and dynamic concept that incorporates the other five sub-themes (personal life, sense of purpose/calling, Del Rio Torres 74 intrinsic characteristics, education and career opportunities, and workplace culture) in the development of resilience. The two light blue arrows symbolize health, healing, tranquility, understanding and softness, all of which help in the development of personal reflection and selfawareness. The participants may not have directly mentioned reflection and self-awareness, but during their interviews they all demonstrated the ability to make informed decisions, revealing their ability to reflect and be self-aware. Participant F demonstrated the ongoing process of reflection and self-awareness by sharing several experiences: But I was really lonely because I had to move to a new city. The nurses there were bitches, pardon my language, but they were miserable, horrible people. When they talk about eating your young, textbook case, like I was out for 3 months. I had a patient who shouldn't have been a code, like if I have spoken up and put on my big-girl panties because the thing was that the problem is that you know you don't know but you're scared to talk, because the people are so unreceptive. And I had this guy who was circling. He had lung cancer; he should have been a DNR from the get-go, but this doctor had him as a full code--not to be determined, but full code, and I was like what? They put in a thorencentesis; he drained so much that the fluid shifted, went hypovolemic; we couldn't get a hold of them to change things. The LPN I was working with, because of team nursing, was not a very strong nurse, and he had just come back from a long time off because he had a heart condition or something. When I asked for help from my other nurses, they brushed me off, and told me to get over it. So I called the code at 6:30. They didn't do much about him; they gave him some dopamine, because remember it was 2001. We did what we could; we tried to fluid resus him, and it became fairly obvious it wasn't going to work, so we just had to let him go and while they are counting and restocking the Del Rio Torres 75 crash cart, I could hear them bitching about how stupid I am. "I can't believe that she's a nurse; how the hell did she get through nursing school; what's wrong with her.” So I'm trying to fill out the resus record, through my tears. That weekend, I moved up there just before Labor Day, and I had a U-Haul booked to move back home by Easter, and quit nursing; I was just done. Initially, she was unable to reflect on this painful experience, until she allowed the healing process to begin, thus developing self-awareness and the ability to reflect. Through these developed skills, many years later, when she was faced with a difficult situation, Participant F was able to reflect on the situation, resulting in a healthier outcome sooner. She had taken a temporary position as a head nurse on a Renal/Gastrointestinal floor; unbeknownst to her, the culture on the unit was toxic. She stated, And I tried to help out as best I could, but the full time CNL wasn’t being that supportive; the manager was [pregnant] and checking out. And I had enough, I was done. The workload was just too much; there was a lot of junior staff combined with all these things, and I was like I just can’t do this anymore. Later in the interview she discussed the same situation, remembering, "I'm sick of being a punching bag here, I'm done. There's only so much she can take. And sometimes you need to move on, and sometimes change is as good as a rest. And that's what I did." Through Participant F's learned skills of reflection and self-awareness, she was able to understand not only how difficult it is to care for oneself and to nurture one's own resilience but also the necessity of emphasizing this message to her patients. Del Rio Torres 76 Developing Reflection and Self-Awareness Reflection and self-awareness are skills that develop through experiencing different challenges. Participant D shared, Having come from fighting my own battles and still going on with my own chronic health I think that has a lot to do with it, because I’ve just learned over a long time that sometimes you just have to keep going. You learn that, I mean I find a big part of it, that understanding that everybody has their own struggles whether or not we can see them. And understanding and accepting that there are going to be challenges makes them easier to face. And knowing that there’s always going to be the good coming with the bad. You know, despite the fact that I’ve been in some of the most awful experiences I’ve had in nursing, have given me good learning in the end, and have developed good relationships, and given me a real chance to decide what I want to focus on in my practice. So I think there’s knowing that good and bad coming; it’s certainly a cycle that way in nursing. In addition, Participant B shared that her process of learning reflection and of developing selfawareness was influenced by colleagues and mentors: Just conversations with older nurses that have been in it a bit longer, that have kind of mentored me, have kind of just, you know, in the middle of a situation, kind of pulled me back and given me a view of what's really going on, and kind of reminded me of why we are in this and what really matters. And so I think, yeah, conversations from other supportive nurses have been hugely beneficial and given me life and have led me to do different education routes, like a conversation with an older nurse in Emerg at [Hospital], actually led me to do my high acuity course not the Emerg course, and others led me to do Del Rio Torres 77 my masters. It wasn’t necessarily totally my idea, but it was reinforced by people outside of me. Participant B's respected colleague was able to pull her out of the middle of her struggle and remind her that she did not need to limit her nursing to the emergency department. Once further from the difficult situation, Participant B was able to reflect on her future in nursing. Participant G's challenges also contributed to the development of her ability to reflect and be self-aware: There are definitely some days though that you go, "I don't want to go." I haven't had that much on the current floor I'm on, thankfully. I had it a lot on a lot of my other floors, that's why I had to leave them. If this is how I feel, I'm going to end up not giving my patient the care they deserve and the care that I want to give. So that's also why I left a lot of my old floors. The participants' challenging experiences enabled them to become reflective and self-aware and positively influenced them as individuals. Through this process, they were able to make sound decisions regarding their nursing career. Knowing Oneself The participants benefited from their reflections and self-awareness to be able to understand what they were capable of in different stages of their careers. Participant H shared, Like I had actually contemplated becoming a PCC when they had posted the lines that were up, and I thought about it but then did I really want to get a paid a tiny bit more and then have to take my work home with me at the end of the day and not be involved with patients directly; because that's why I enjoy my job because I'm actually with the patients and the families doing hands on stuff and not having to deal with any of the politics stuff because that stuff is not enjoyable to me. Del Rio Torres 78 Similarly, Participant C made a career choice because of her reflection and self-awareness. She stated, "I don’t think I could do hospice full time, and I know I couldn’t do oncology full time." Reflection and self-awareness not only influenced their nursing careers: two of the participants spoke of decisions they made outside of nursing because of their ability to reflect. Participant C stated, I am going to be starting working casually for a pre-school, so I’m going to be working around little kids, and I think that’s just going to add to reminding myself that it's not always death and dying, and it’s not always sad. She continued, " So, I think my want to work with the preschool, just sort of filling in here and there, is going to help top up that cup, to what makes me feel whole." Participant E shared her priority that she was able to determine her priority through her own reflection. She stated, Because my intention is to be as much of a stay-at-home mom as I can while my kids are young. ...[And] that's what it is for us right now, like how much do I keep working to keep my license, or do I actually decide to give up nursing and go back to it in 15 years or something like that. Haven't quite figured it out. So in the meantime I'm keeping my toe in the door. The participants did not directly mention their ability to reflect and be self-aware, but their stories and experiences demonstrated this ability. Several of the participants shared stories about how their development of their ability to reflect and be self-aware, that later influenced their life as a whole. The data shows that this final sub-theme is essential in development of resilience. Flourishing Through their personal stories, the participants demonstrated their resilience, and their ability to rise above many challenges and to positively change their own outcomes. The different Del Rio Torres 79 aspects that develop and shape individual resilience include personal life; a sense of purpose/calling; intrinsic characteristics; education and career opportunities; workplace culture; and reflection/self-awareness. In the pictorial diagram, flourishing is represented by the dark blue on the right-hand side. When all aspects of resilience are healthy the individual is able to flourish. The dark blue symbolizes knowledge, integrity, and the power of flourishing. When an individual is flourishing, his or her positivity becomes apparent in the environment and influences others, therefore demonstrating the power and strength of flourishing. The participants were asked two specific questions related to flourishing. The first question was "What is it about the "heart of nursing" that must be maintained to enable you to flourish as a nurse?" The participants struggled answering this question and were encouraged to disregard the challenges they regularly face when considering the question. The second question was "What ways can we as nurses transform our workplace to create and sustain flourishing nurses?" The majority spoke of different factors influencing their ability to flourish. Participant B stated, And I think it's a good opportunity to have the 'drive' to get beyond the status quo and to flourish. But I think there are a lot of nurses that see it the way it is; I think it takes a lot of personal drive to move beyond that, and, I guess, flourish. Flourishing is being able to go above the ordinary and thrive, as demonstrated in Participant C's words: But I think still loving what you do enables you to give that to the patients... ...For me anyways, I know there are some days it’s like it's been a horrible set, and I've still got one more night to go, and it’s like let’s just get through this, but I still enjoy it. The connections with the patients we make, even if they're only the patient overnight, it's just Del Rio Torres 80 really so rewarding to be there, even if it's just taking five minutes sitting on the edge of the bed: "I hear you got some rough news today, do you want to talk, or do you just want to sit," and just giving them that presence of you being there. Her love of nursing enables her to sit down and bond with her patients and go above and beyond the expectations of nursing today. Although there is little research on flourishing, the participants were able to point out factors negatively impacting their ability to flourish. An individual can only flourish if all aspects of resiliency are in a healthy balance; if not, flourishing cannot occur. It is important for individuals with resiliency and the ability to flourish to remember the influence they can have on their surroundings. Participant B shared, "When you see certain nurses doing that, I think other nurses realize that it's possible too. So I guess I'm saying, leading by example." When someone is flourishing, he or she has an indirect impact on the people they come across. Chapter Summary In this thesis, nine acute care nurses working in BC were interviewed in order to discover 'what keeps the nurse ticking'. The participants shared personal experiences that demonstrated how each participant was able to rise above difficult circumstances they faced. The pictorial diagram (Appendix E) visually displays how the participants developed their resilience and, at times, are flourishing in their nursing. Resilience is portrayed through an exploding orange star surrounded by six sub-themes that all contribute to the development of resilience. Each participant spoke of these subthemes experienced in his or her personal and professional life: personal life, intrinsic characteristics, sense of purpose/calling, education and career opportunities, workplace culture, and reflection and self-awareness. As long as the skill of resilience is established, an individual may remain resilient even when all subthemes are not in Del Rio Torres 81 order. However, flourishing only occurs when all six subthemes are in a healthy state, enabling a strong resilience, as well as the ability to flourish. When a nurse flourishes, positivity radiates in everything he or she does. Nurses may face a challenging patient or difficult situation but they are still able to flourish because the foundation of their resilience is well established. Their flourishing will influence their colleagues, department, and impact their patients and their families. Del Rio Torres 82 CHAPTER FIVE: DISCUSSION This chapter discusses my thesis findings (Chapter 4) as related to the academic, empirical literature. Initially, I remind the reader of the study's purpose: to examine nurses' resilience in relation to unhealthy work environments. I then bring literature about self care, sense of purpose/calling, workplace culture, and reflection and self-awareness to bear on the study findings. Finally, I review what my study adds to the current literature. Review of the Problem Nurses are facing numerous challenges in healthcare today that create an unhealthy work environment. Many stereotypical views of nurses are evident within public opinion. Some of the negative opinions are that nurses only do as 'ordered' by the doctor and that they are merely doctor's assistants (American Society of Registered Nurses, 2007). In large part, public opinion is influenced by how the media presents nurses. Not only are nurses working within a negative public opinion, they are working in an environment with short staffing, budget cuts, aggressive patients, relational aggression from patients and colleagues, and secondary trauma (Advisory Committee on Health Human Resources, 2002; Brunt, 2015; Eggertson, 2011; Morley, & Burns, 2016). Many nurses have accepted violence and aggression as simply being a part of the working culture. The Association of Registered Nurses of British Columbia (2017) has found that 18% to 30% of new graduates will change practice environments in the first year, and up to 37% to 57% will leave nursing in their second year. Working in an unhealthy environment negatively impacts an individual's psychological, emotional, and physical well being. Yet, regardless of the challenges that nurses are facing today, some are able to rise above them because of their resilience and are able to flourish. The purpose of this thesis was to understand Del Rio Torres 83 the life-giving factors that allow nurses to be resilient and flourish in a negative and challenging environment. What the Literature Says In research, the concept of resilience is loosely defined with broad attributes that describe the concept as a necessary response to the negative environments that nurses are currently experiencing. My study explores the concept of resilience from a positive perspective. Thus, it views resilience as developed through the following six subthemes: personal life; a sense of purpose/calling; intrinsic characteristics; education and career opportunities; the workplace culture; and reflection and self-awareness. Self Care Personal life is the first subtheme influencing the development of resilience. One aspect of personal life is self care, is a concept often emphasized within the nursing community. Two available resources to help nurses in BC focus on their self care are provided through the British Columbia Nurses Union and through healthcare authorities that offer free resources through their Employee Assistance Programs. The World Health Organization (2013a) defines health as not merely being free from illness or disease but as a complete state of physical, mental, and social well being. Self care is when an individual initiates and completes activities that maintain his or her life, health, and well being. A result of self care is self-awareness, self-efficacy, and confidence (Grafton & Coyne, 2012). Furthermore, the British Columbia College of Nursing Professions [BCCNP] recognizes the necessity of self care in its professional standards for all nurses in BC. We are required to maintain our "...own physical, psychological and emotional fitness to practice" (British Columbia College of Nursing Professionals, 2018). Del Rio Torres 84 Self care activities vary among individuals, so it is essential individuals choose activities that are congruent with their personal beliefs and culture (Grafton & Coyne, 2012). The World Health Organization (2013b) promotes a healthy diet and physical activity, as well as activities facilitating emotional well being and health. As stress cannot be avoided, individuals must find appropriate strategies to work through their stress so they can relax and de-stress. Some such activities include strengthening relationships with family and friends; participating in community and religious activities; meditation; proper rest and sleep; hobbies and fun activities during leisure time (World Health Organization, 2013b). The literature, including grey literature from organizations such as WHO, has strong consensus about the importance of self care. And common sense also tells us self care is important. Nurses are, for the most part, aware of the importance of self care; however, in reality, self care is often neglected or given little attention in the nursing profession (Mills, Wand, & Fraser, 2015; Nahm, Warren, Zhu, An, & Brown, 2012). In fact, some have labelled self care as 'responsible selfishness' (Mills, Wand, & Fraser, 2015). All participants in my study valued self care and identified a variety of activities that contributed to their self care, including their physical, psychological, emotional, and spiritual needs. Several of the participants expressed how faith is a vital component of their personal life. Each mentioned the importance of prioritizing their family over their career. Even though family was significant to the participants, some shared their loved ones' lack of understanding of what they experience because of the difficult nature of nursing. Nonetheless family remained important in their lives. The academic and grey literature helped to trace the link between self-care, resilience, and selfefficacy, and confidence (Grafton & Coyne, 2012) providing more understanding of how the participants' resilience was enhanced by their self care. Del Rio Torres 85 Sense of Purpose/Calling A sense of purpose/calling is the second subtheme that influences the development of resilience; however, little research has been done on this subtheme. Hall and Chandler (2005) defined calling as a work that a person perceives as his or her purpose in life. In earlier research, a calling had a religious connation; however, Hall and Chandler characterized a calling as an individual process providing a strong sense of inner direction that contributes to a better world. The concept of calling incorporates several aspects. First, an individual's calling is unique. Second, it involves preconditions; the individual must have talents and abilities to work within his or her calling. Third, a result of working within one's calling is energy and enjoyment. Finally, Hall and Chandler (2005) acknowledged that to discover one's calling is not an easy process but one that requires reflection, conversations with others, trial activities, and persistence. However, when individuals are working within their calling and are facing difficult situations or unfamiliar grounds, they are more likely to manage temporary setbacks, failures, or challenges because their underlying inner direction helps them navigate through complex situations with the understanding that they ultimately will succeed (Hall & Chandler, 2005). A sense of purpose/calling is also a common theme in research carried out by Christians. Will Mancini (2010) talks about "your kingdom concept" (p. 85) from a Christian perspective that informed the model I employed in my data analysis (see Chapter 4). He uses a pictorial diagram consisting of three overlapping circles. The first circle represents gifts and abilities. Individuals must have the gifts and abilities to work within their sense of purpose. The second circle is passion. Individuals must consider what they are passionate about or what they like to do when working within their sense of purpose. The final circle is locality. What are the unique needs and opportunities where one resides? For example, if an individual believes his or her Del Rio Torres 86 sense of purpose involves working within a rural community but really wants to reside in a large city, locality may need to be reconsidered. The middle area where all three circles overlap is labelled the "kingdom concept"; this is where the individual is best equipped to fulfill his or her calling (Mancini, 2010). Even though these authors have taken different approaches, a secular one and a Christian approach, they share similarities. Both resources acknowledge one must have strengths, abilities, and talents to work within one's calling. In my study, the participants either directly or indirectly referred to a sense of purpose/calling throughout their interviews. Three participants spoke of a religious sense of purpose, whereas all of the participants spoke of an inner direction of wanting to make a difference. The participants shared stories of being encouraged and re-energized as a result of working within their sense of purpose/calling. Will and Chandler (2005) also reported that individuals experience an energized and encouraged outcome as a result of working within their sense of purpose/calling. During the process of data analysis, after a sense of purpose/calling emerged as a theme, I had some informal conversations with individuals, some with and some without a faith. I asked questions such as, if money were no option, what would you do with your time? When things are tough, what gives you strength, or where do you find your strength? Who do you identify yourself as? The myriad of answers was surprising. Quite a few people were unable to answer the questions. Some answers were specific, others were vague, and yet others from individuals with a foundational faith did not point towards Christ. These informal conversations point towards the difficulty of finding one's sense of purpose/calling whether or not one has a faith. Similarly, in my study, some participants were unable to speak specifically of their sense of purpose/calling: however, it was evident that they had a desire to make a difference. A sense of Del Rio Torres 87 purpose/calling also relates to the third subtheme, which features intrinsic characteristics broken down into three categories: positivity; a dedicated and unrelenting spirit; and a caring nature. One's intrinsic characteristics are more transparent or evident when working within one's purpose/calling. Workplace Culture Workplace culture is another subtheme that influences the development of resilience. "The "culture" of a workplace includes psychosocial aspects such as leadership style, management practices, the way in which work is organized, employee autonomy and control, and social support" (Healthy Families BC, 2012, para 1). The workplace's organizational culture influences the employee's health; a positive culture brings out the best in employees, developing a mutual trust and respect among them (Healthy Families BC, 2012). Workplace culture also impacts worker retention. In July 2003, the Registered Nurses Association of Ontario (RNAO) recognized two dynamics impacting the nursing shortage; first, the type of work nurses are doing and second, the environment nurses work within. It began developing best practice guidelines to encourage and promote healthy work environments for nurses in hopes of reducing the nursing shortage. The Association's overarching definition of a healthy work environment is "... a practice setting that maximizes the health and well-being of nurses while ensuring improved organizational performance and the best possible outcomes for patients, their families, and the community" (Registered Nurses Association of Ontario, 2017, p. 6). It is critical to achieve healthy work environments for nurses for safety, recruitment and retention purposes (Registered Nurses Association of Ontario, 2009). RNAO established several foundational healthy work-environment best practice guidelines that are relevant to the findings of this study. Establishing a healthy work environment is a Del Rio Torres 88 complex and multi-dimensional process. It requires interdependence between the individual, organization, and the external system, which includes the community and society as a whole. The main topics covered in the guidelines are collaborative practice in team nursing, effective staffing and workload practices, nursing leadership, cultural diversity, professionalism and workplace health, safety and the well being of nurses. The "Collaborative practice among nursing teams" (2006) guideline discusses the necessity of teamwork in a healthy workplace culture. RNAO acknowledges that nursing is about relationships that affect everyday interactions with colleagues and patients/families. As per the guidelines, it is essential that nurses become skilled team players and team leaders working in environments that are constantly changing. Effective teamwork includes motivation, accountability for one's actions, commitment to the team, being proactive, and open communication, including active listening. An example of effective teamwork is when collaboration occurs with an increasing patient acuity, resulting in better outcomes. A healthy workplace culture is fostered through effective teamwork. In my study, all participants valued teamwork and their relationships with colleagues on their unit. They shared stories of teamwork in difficult circumstances that improved their patients' outcomes as well as positively influenced their workplace culture. RNAO's clinical practice guideline called "Developing and sustaining safe, effective staffing and workload practices" (2008) discusses how a safe environment for nurses indirectly impacts the patients. RNAO does not give a specific nurse-patient ratio, but makes recommendations in order to implement this guideline effectively. At the organizational level, RNAO has created several recommendations to ensure a safe working environment that contributes to a healthy workplace. These recommendations include organizations developing a Del Rio Torres 89 plan ensure safe staffing levels in collaboration with point-of-care nurses and nurse leaders who understand the department's needs and skill sets. Another recommendation is to create a clear communication tool or strategy to address staffing needs in unexpected situations. RNAO has created several recommendations for individual nurses. Nurses must communicate effectively within their team and have an awareness of their colleagues' education and skill sets, as well as understanding the needs of patients. Point-of-care nurses must also be aware of how to document and report unsafe practices to their regulatory body and their organization. Finally, point-of-care nurses must be involved in the development and operation of staffing, allowing relevant frontline information to be brought forward in order to generate advocacy for safe staffing. These recommendations allow for safe staffing levels as well as ensuring an adequate skill level on the unit. RNAO believes when units are staffed safely and appropriately, nurses feel safer and patients are safely and effectively taken care of (Registered Nurses Association of Ontario, 2008). In my study, the participants valued working in a safe workplace that contributed to their resilience. The participants shared their desire to work within safe staffing levels -- and when the acuity changed, having the ability to voice their concerns and have more staff brought in if necessary. RNAO has other clinical practice guidelines for a safe working environment that promote a healthy workplace culture. One aspect of a healthy workplace culture is minimal violence or aggression. Thus, RNAO developed the guideline, "Preventing and managing violence in the workplace" (2009). It defines violence as "an incident of aggression that is physical, sexual, verbal, emotional or psychological that occurs when nurses are abused, threatened or assaulted in circumstances related to their work” (Registered Nurses Association of Ontario, 2009, p. 30). This guideline recognizes the current concern about violence in the workplace and makes Del Rio Torres 90 recommendations in order to minimize or mitigate the issue, thus promoting a healthy environment. In my demographic and nursing history survey, each participant admitted to working with physically and verbally aggressive patients. Eight of the nine participants had experienced a culture that accepted violence as a part of their job. However, in my interviews with participants, violence in the workplace was not a common theme, perhaps because I chose to instead focus on positive aspects influencing resiliency. "Developing and sustaining nursing leadership best practice guideline" (2013) discusses how effective leadership in nursing can result in healthy outcomes for nurses, patients and the organization. RNAO speaks to the organizational level of leadership: leaders must be visible, understanding, and value the critical role nurses play in patient care, must be aware of sufficient and appropriate financial resources, provide necessary decision making support and create a workplace environment conducive to effective and efficient nursing care. RNAO identifies five qualities of transformational leadership. First, a critical and foundational concept is that leaders must build relationships and establish trust between the nurses, teams and different partnerships. Second, it is important to create an empowering work environment. An empowered work environment will have access to information, education, support, resources, and opportunities to learn and grow, promoting autonomy and colleague support. The third quality of transformational leadership is a culture that supports knowledge development and integration. This culture instills a continuous inquiry approach to improve clinical and organizational processes and outcomes. Fourth, the leadership must be actively involved in the implementation and sustaining of change. Finally, transformational leaders must balance the complexities of the system with competing values and priorities. This balance occurs when the leader advocates for nurses enabling high quality patient care, while also understanding the multiple complex Del Rio Torres 91 demands of the organization (Registered Nurses Association of Ontario, 2013). In my study, the participants discussed two levels of leadership on their units. First, they valued frontline leadership; they shared the importance of their charge nurses being available, intervening when needed, and advocating for their staff. Second, the participants identified characteristics of good management, including having an open-door policy, being available to the staff, working through problems as they arise, and having effective communication skills. Successful leaders collaborate with the unit members to meet their needs, resulting in a positive workplace culture. In summary, RNAO has developed several clinical guidelines that promote and encourage a healthy workplace culture. Some aspects of a positive workplace culture include teamwork, a safe environment with minimal violence and aggression, and effective leadership. RNAO's guidelines for a healthy workplace culture support the evidence gathered from the participants in my study. Participants identified the same attributes of a positive workplace culture that help to develop their own resilience, as is visualized on the pictorial graph under the subtheme, workplace culture. An array of research validates the participants' desire to work within a positive and educated workplace culture. Reflection and Self-Awareness Reflection and self-awareness are the final subtheme influencing the development of resilience. Reflection is learning through everyday experiences. Wain (2017) discusses three different learning cycles shaping the process of reflection. Initially the individual reviews the situation and works through what has happened. There are many ways to reflect on the situation: asking questions, identifying accomplishments in order to look forward, considering feelings and experiences, considering the influences involved, and considering how to respond in the future. The practice of reflection is beneficial for numerous reasons. On a professional level, reflection Del Rio Torres 92 helps individuals gain a deeper understanding and an ability to evaluate, increasing their critical thinking skills, as well as informing their practice and integration of the practical and theory. Reflection helps individuals to explore the influences that have shaped and guided not only their individual practice but also their personal life. Reflection increases self-awareness, self-identity, personal growth, and personal fulfillment, thus helping the individual to see things clearly and make a sound decision. Subia Rasheed, a nurse in Spain discusses reflection and self-awareness in her view paper. She asserts that reflection facilitates the opportunity to review and analyze our actions and experiences and benefits our personal growth. One can choose to appreciate positives and learn from negatives (Rasheed, 2015). Self-awareness is a dynamic and transformative aspect of reflection: "Self-awareness is getting to know about oneself as a person and the important things in life which influences us in different ways. It also includes the reflection on how our attitude and beliefs can influence others" (Rasheed, 2015, p. 212). Reflection and self-awareness may not initially be calming, sometimes the process is painful and unpleasant, but it can result in healing and understanding. In my study, through their process of reflecting on different situations, the participants shared stories of disappointment and hurt that facilitated their ability to be reflective. This ability enabled them to make sound decisions that positively influenced both their practice and their personal life, furthering their self-awareness, self identity, and personal fulfillment. Several participants shared how earlier difficult experiences helped to develop their ability to be reflective and gain self-awareness, and how this later positively influenced their career decisions. In the literature, the subthemes of self care, sense of purpose/calling, workplace culture, and reflection and self-awareness are discussed separately from resilience. In my study, the Del Rio Torres 93 participants demonstrated that these subthemes are essential life-giving characteristics influencing their personal development of resilience. What my Study Adds to Literature My study adds some unique dimensions to existing research, providing a productive innovative alternative to the emphasis in the nursing literature on burnout, moral distress, and similar negative concepts. Current research has revealed that nurses today are facing numerous adversities on a daily basis that increase the difficulty of their job, as outlined in this thesis' introduction and this chapter. In contrast, my study employed an Appreciative Inquiry approach that focuses on life-giving factors that help nurses to be resilient and flourish within stressful and unhealthy environments. Until now, research literature has only broadly identified attributes influencing resilience and flourishing. In contrast, my study has clearly identified the essential contributing factors to the development of resilience. The research literature is also vague about the concept of flourishing. In contrast, my study clearly defines flourishing and illustrates through the pictorial graph and discussion how an individual is able to flourish. My study also contributes some unique aspects to the subthemes identified as influencing the development of resilience. My analysis of the data gleaned from the interviews with the participants reinforces the value of building a personal life apart from the professional realm. My analysis also revealed that one unique aspect of this subtheme is faith. The participants discussed the significance of their faith and how it influenced and strengthened their resilience. Another unique aspect of this subtheme was finding that the participants valued prioritizing their family over their work. Significantly, my study found that the participants experienced a lack of understanding from their families about the challenges nurses face in their workplaces. Nonetheless, participants valued their family more than their careers. Another unique subtheme Del Rio Torres 94 was the sense of purpose/calling that influenced the development of the participants' resilience. It became clear after examining the research that this is an understudied topic, yet my study clearly indicates the value of this aspect. Current research provides little supporting data about the connection between reflection and self-awareness and resilience, but my study establishes the significance of reflection and self-awareness in the development of resilience. Overall, my study contributes unique and constructive data to an area where research has typically presented negative aspects. Chapter Summary The array of adversities and challenges that nurses are facing today in their workplaces is well documented in the literature. This chapter has examined the subthemes emerging from my data in the context of existing research. A significant amount of research evidence validates the significance of self care and a positive workplace culture. My results verify these findings. However, little research exists on how a sense of purpose/calling and reflection and selfawareness contribute to the development of resilience. My study thus adds a unique perspective in contrast to the extensive existing research on the negative aspects of today's nursing. As an alternative, my study presents a positive and distinctive action research approach that identifies the life-giving characteristics required in the development of resilience. My study also examines the correlation between resilience and the ability to flourish and rise above the status quo in nursing. Del Rio Torres 95 CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS This chapter begins with a summary review of the study as well as of its key findings. Next, it discusses recommendations emerging from my thesis requiring further research in leadership/administration, individual practice, policy, and finally, education. Lastly, it reviews the limitations of this study. Summary Review and Key Findings This study, using the Appreciative Inquiry method, investigated the core values, individual characteristics, external factors, and support systems that allow nurses to persevere during adversity in the workplace, develop their resilience, and flourish through both good and challenging times. Previous research demonstrates that nurses often work within unhealthy environments, but little research examines the life-giving qualities that contribute to their resilience and ability to flourish. I wanted to find a practical solution to assist nurses in these negative environments that would benefit the individual nurse, the patient, and the employer. The questions this study asked were, "What are the attributes/core values/characteristics that keeps the nurse going in difficult situations at work?" and "What framework/model/pyramid will empower the individual nurse and employer in fostering a positive atmosphere in their working environment?" The key findings of my study are depicted on the pictorial graph, demonstrating six different subthemes that influence one's ability to be resilient. Resilience is grown, shaped and molded through personal life, a sense of purpose/calling, intrinsic characteristics, education and career opportunities, workplace culture, and reflection and self-awareness. The results of the study indicate the aspects required for nurses working within a difficult environment to build resilience. My conclusion is that an individual may still be resilient even if not all of the six Del Rio Torres 96 aspects that facilitate resilience are in order, but to be able to flourish, all six aspects must be in a healthy state. Recommendations The following recommendations are based on the results of my research. Research Initially, my research looked into the concepts of resilience and flourishing in the existing literature and found the current research inadequate. There was more information in the literature on resilience than on flourishing; however, examinations of both concepts were lacking in depth and consistency. My initial, broad recommendation is that more research needs to be done on the importance of resilience and the characteristics that develop resilience, as well as on creative techniques for sharing this knowledge so it reaches frontline staff. Similarly, more research is needed on flourishing and the ability to flourish positively influences one's environments. Research is also lacking on some of the key subthemes my study identified as crucial to developing resilience. I recommend further research to more fully examine these subthemes. The first subtheme, personal life, covered three areas and two in particular would benefit from additional research. The first was self care. An array of research emphasizes the value of self care, the majority of which shows that nurses are ineffective with their self care. More research is needed on innovative strategies to implement and encourage self care in nurses. The second point the participants shared was their prioritizing of their family over their career. This point came with a shared concern. Participants identified that they often experienced a lack of understanding and support from their family members for the adversities and challenges they Del Rio Torres 97 faced at work. This fascinating phenomenon requires more research on how nurses could bridge the gap between their prioritizing of family and their receiving support from family. My recommendations for the second and sixth subtheme are similar. My study identified a sense of purpose/calling as an important aspect in the development of nurses' resilience. However, little research has examined this dimension. Also, individuals struggle with identifying their sense of purpose/calling. Further, research is recommended to examine the subtheme of a sense of purpose/calling and consider some creative strategies to encourage individuals to consider their purpose/calling. Some existing research examines reflection and self-awareness. My study demonstrates the significance of this continuous and dynamic concept that incorporates the other five subthemes in the development of resilience. More research is needed to emphasize the need for more education about this essential subtheme and to create innovative strategies to publicize this essential aspect of resilience. Leadership/Administration My thesis has generated several recommendations that will strengthen leadership and administrative roles in healthcare. My initial recommendation supports the RNAO's guideline "Workplace health safety and well-being of the nurse" (2008). RNAO developed this guideline in order to decrease unhealthy working conditions and create a healthy culture in order to promote the health and well-being of nurses. The RNAO supports the World Health Organizations definition of health: health is an important concept in our daily lives and is influenced by our beliefs, circumstances, culture, actions, and economic and physical environments. To be healthy enables a meaningful life. RNAO explains well-being as an individual's ability to experience physical, mental, and psychosocial health. An individual's well-being is measured in relation to their professional fulfillment, mental energy, and work- Del Rio Torres 98 related exhaustion. Organizational well-being is measured in relation to efficiency, personal development, autonomy, workload, work environment, and leadership. This guideline includes recommendations to improve the well-being of both the organization and individual nurses: "Creating and maintaining healthy workplaces will be critical if nurses are to be successfully recruited and retained. ... Ensuring the health, safety and well-being of the current and future nursing workforce is vital to the future of the health care system" (Registered Nurses Association of Ontario, 2008, p. 19). In order to create healthy work conditions and a healthy workplace culture, leaders need to begin a culture shift on their individual units and areas. This process is not simple; however, by implementing some of my other recommendations a culture shift can slowly begin. My next two recommendations came directly from the participants in my study who identified two levels of leadership. The roles and responsibilities of charge nurses may need to be re-evaluated and to become more consistent throughout the healthcare system. Currently, some charge nurses are known to 'disappear' when their unit is struggling the most, and this action is unacceptable. One of the participants suggested the charge nurses on the floor rotate every several months into a patient care assignment so they have a genuine understanding of what frontline nurses are experiencing and are more willing to help when needed. My study identified characteristics should be incorporated into the work description for a charge nurse: charge nurses must be available to their staff, must be able to identify the needs of the unit on a day-to-day basis and assist their nurses when they are struggling. For example, they should help with simple tasks such as testing a patient's blood sugar, doing vitals, or moving a stretcher or re-siting an intravenous when the unit is overcapacity or short staffed. I recommend that charge nurses be Del Rio Torres 99 required to be hands on and be able to identify the current needs of their department and to advocate for their department as needed. The second level of leadership is the unit managers. The participants in my study clearly identified the characteristics of a good manager. Therefore, my recommendation is that all managers strive to achieve these realistic characteristics and establish an accountability procedure to ensure they are meeting these requirements. An effective manager has an opendoor policy, works through problems as they arise to the best of his or her ability, has effective communication skills, and is available to the staff. The manager should check in with the charge nurse and frontline staff on a regular basis. Supportive management encourages their staff to voice their concerns, provides education about what resources are available for their staff (e.g. the employee assistance program) and encourages them to pursue further education and various opportunities that advance their knowledge and expertise. Finally, effective management should support the employer's policies and provide education about these policies. For example, Fraser Health Authority has a Violence Prevention policy. Management must advocate and ensure their frontline staff are reporting violent and aggressive behaviours or episodes to Workplace Health. After an incident has been reported, management must complete their follow-up responsibilities, as well as ensure their frontline staff are psychologically fit after the incident. When management supports the Violence Prevention policy, it demonstrates to their staff that the frontline nurses are not required to accept violence as part of their job, thus enabling a change in the culture. My ultimate recommendation for management/administration is to begin a culture shift in their units and hospitals. If frontline staff are witnessing their management/administration advocating for a healthy workplace, demonstrating their own healthy Del Rio Torres 100 behaviours and being available for their staff, it will be the beginning of a culture shift that introduces a healthy work environment for their frontline staff. Implications for the Individual Practice My thesis generated several recommendations for individual nurses. It is essential to acknowledge that each individual is responsible for his or her own self and should not accept the current status quo as a healthy work environment. First, individual nurses should partake in the recommended and available education on resilience and flourishing. Information about available education and resources on self care, a sense of purpose/calling, reflection and self-awareness and resiliency should be posted in a prime location where all frontline staff can see what is available. When nurses are aware of these concepts and of the essential characteristics of resilience, they can choose to make changes and develop their own resilience. My second recommendation is that frontline nurses must do their part in the culture shift initiated by management. This includes voicing their concerns, being involved in change, and being a frontline voice for policy change. My third recommendation is that a friendly competitive wellness program be established throughout hospitals, promoting the essential characteristics of resiliency. A simple point system could help each unit keep track of their participation in the different activities that support the program. At the end of every month, the winning unit could be recognized throughout the hospital and given a small reward to acknowledge their achievement. This system may also positively influence the culture shift. My final recommendation is to have a chaplain available for healthcare employees twenty-four hours a day. The chaplain should briefly check on all the units daily, touching base with employees from all the different shifts. Posters could provide education to the employees about the chaplain's role; in addition, information could be provided to nurses to let them know when the chaplain is Del Rio Torres 101 available. This information would introduce the new program which would provide a non-biased and confidential resource for nurses to encourage self care and reflection and self-awareness. These recommendations support self care, family first, a sense of purpose/calling, and reflection and self-awareness, hence building resiliency. Policy Currently, policies already in place influence some of the characteristics required for resilience. However, some of the policies are too unrealistic and out of touch with what is actually happening on the frontlines. For example, regardless of Fraser Health Authority's Violence Prevention policy, violence is still occurring and sadly is tolerated or accepted as 'normal' within the frontlines. Perhaps another reason an aggressive and violent environment is tolerated is the lack of provincial and legal support for our nurses. Earlier in 2018, the provincial government announced new legislation affecting first responders, sheriffs and correctional officers (Province of British Columbia, 2018). Previous legislation required first responders to prove that mental disorders such as post traumatic stress disorder are work related. The change in legislation recognizes that mental disorders are presumptive conditions associated with specific jobs and caused by the nature of the work and thus are not required to be proven as job related. The Labour Minister spoke of providing fairness and support for these individuals who risk their lives as part of their jobs. Unfortunately, nurses were excluded from this legislation. Christine Sorensen, the acting president of the British Columbia Nurses Union at the time, stated, "This announcement discriminates against those point-of-care nurses who are psychologically impacted from providing care in traumatic situations taking place in acute, residential and community-based settings" (British Columbia Nurses Union, 2018, para. 2). Thus I recommend Del Rio Torres 102 that the provincial government and courts change this legislation to include nurses; this change would support the health authorities in working towards creating a healthy workplace culture. I recommend that when policies are developed the health authorities include key stakeholders with current frontline experience, enabling the voice of frontline workers/nurses to influence and speak practically into the desired policy. If part of policy development includes paying attention to realistic feedback from frontline nurses, there will be more buy in from all of the frontline staff. And finally, there must be an ongoing evaluation of the effectiveness of the policy's implementation to assess if changes are needed. Education My study generated two recommendations for the educational initiatives. The first is that the provincial regulatory bodies of the Registered Nurse and Licensed Practical Nurse programs ensure a core competency for all new graduates that includes a basic understanding of the lifegiving characteristics essential to developing resilience and of the concept of flourishing. These concepts should be amalgamated into current curriculum for all nurses. New graduates must be made aware of the concepts of resilience and flourishing prior to starting their careers. The second recommendation is for nurses already in practice. Practical and hands-on education is needed to educate nurses about the significance of their own resiliency and ability to flourish. Mandatory, paid participation in such a course will prepare frontline nurses to participate in the necessary culture shift. Limitations The main limitation of my study was the lack of existing research on resilience and flourishing. As the researcher, I found it difficult to build on previous research because it was not available. An array of research examines the negativities that nurses are currently facing but Del Rio Torres 103 little research has explored how some nurses not only remain resilient but are able to flourish. The second and third limitations affected each other. Due to time constraints, the participants resided and worked only in British Columbia thus creating the geographical limitation. If time was not a limitation, a larger sample size from across Canada would have created a more indepth thesis. Summary My study has resulted in a practical approach to not only current research but also to strengthening nurses who are working amidst adversities and challenging environments. My study discusses the value and significance of the concepts of resilience and flourishing. It demonstrates and visualizes six different characteristics essential for the development of resilience that enable the individual to not only survive difficult environments but also to thrive. Significantly, this research does not only apply to nurses in challenging environments but could also be applicable for individuals in other professions. Finally, this study makes several recommendations to translate this research into practice in hopes that the results of my study may make a difference. Del Rio Torres 104 References Advisory Committee on Health Human Resources (2002). Our health, our future: Creating quality workplaces for Canadian nurses. 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Del Rio Torres 111 Appendix A: Table Outlining the Preliminary Literature Review Date Database Search September -Canadian Nurses Association 2015 -American Nurses Association Keywords Results -respect, workplace (reviewed policy from each organization) -College of Physicians and Surgeons -Fraser Health Authority -British Columbia Nurses Union -Worksafe BC October 2015 CINAHL -nurs* -"lateral violence" OR "horizontal violence" 715,307 223 -bullying OR harassment 7,238 -"lateral violence" OR "horizontal violence" OR bullying OR harassment 7,348 -hospital OR worksite OR "emergency department" OR healthcare 631,338 -nurs* AND "lateral violence" OR "horizontal violence" OR bullying OR harassment AND hospital OR worksite OR "emergency department" OR healthcare 473 (limiters: English only, 2000current 416 (10 articles chosen for review) Del Rio Torres 112 January 2016 PsychINFO -flourish* 3,253 -nurs* 126,097 -climate 27,460 -culture 157,680 -environment 256,946 -flourish, nurs* 117 (limiters: English only, 2000current) 108 (6 articles chosen for review) January 2016 Business Source Complete -flourish* 5,492 -nurs* 75,174 -climate 105,120 -culture 173,615 -environment 351,374 -flourish, nurs* 30 (limiters: English only, 2000current) 23 (0 articles chosen for review) March 2016 CINAHL -nurs* 715,307 -bull*, harass*, "horizontal violence", "lateral violence", "relational aggression", "workplace aggression" 14,630 -nurs*, bull*, harass*, "horizontal violence", "lateral violence", "relational aggression", "workplace aggression" 2,624 Del Rio Torres 113 (limiters: English only, 2000current) (limiters: Canada, peer reviewed) 2,189 49 (3 articles chosen for review) March 2016 CINAHL -nurs* -flourish*, resilien* 715,307 6,515 -workplace, climate, culture, environment, hospital, healthcare 775,836 -nurs*, flourish*, resilien*, workplace, climate, culture, environment, hospital, healthcare 456 (limiters: English only, 2000current) 380 (10 articles chosen for review) Del Rio Torres 114 Appendix B: Demographic and Participant Nursing History Survey What Characteristics are Keeping Nurses Flourishing in Difficult Environments: An Appreciative Inquiry Study Demographic and Participant Nursing History Survey Instructions: Please clearly identify your choices. 1. What is your gender? ___ Male ___ Female 2. What is your age range? ___ 20 - 30 ___ 31 - 40 ___ 41 - 50 ___ 51 - 60 ___ 61-70 3. What is your cultural background? ______________________________________________________________________________ 4. What is your primary language? Do you speak a second language? If so, what is it? ______________________________________________________________________________ 5. What education have you completed in nursing? ___ LPN ___ Diploma ___ Degree ___ Masters ___ Specialty Education ___ Other 6. What aspects drew you into nursing? (Select all that qualify) ___ money ___ the ability to help others ___ to make a difference ___ various working opportunities ___ flexibility ___ the science behind nursing ___family members as nurses ___ opportunity for further education ________________________ ___ job security ___ a trusted profession ___ other please specify 7. What is your employment status? ___ Full time ___ Part time ___ Casual Del Rio Torres 115 8. How many years of nursing experience do you have? ___ 3-5 - 30 ___ 6 - 10 ___ 11 - 15 ___ 16 - 20 ___ 21 - 25 ___ 26 9. What are your previous areas of nursing? ______________________________________________________________________________ 10. Where area(s) of nursing are you currently working in? How long have you worked in these areas? ______________________________________________________________________________ 11. What factors contributed to you deciding to work in your current field of nursing? ___ hours ___ personal relationships ___ excitement ___ location ___ indirect impact on family ___ constant change ___ supportive environment ___ patient complexity ___ learning opportunity ___ other please specify ____________ ___ previous positive experiences 12. What different healthcare professions do you currently work with? ___ RN's Therapy ___ LPN's ___ Care Aides ___ Managers ___ Physicians ___ Physical Therapists ___ Social Workers ___ Dieticians ___ Nurse Practitioners ___ Pharmacists ___ CNE's ___ unit clerks _______________________ ___ other ___ Occupational ___ SLP please specify 13. Have you experienced any of the following in your nursing career? ___ Positive public opinion of nursing ___ Negative public opinion of nursing ___ Short staffing ___ Secondary Trauma ___ Caring for/dealing with physically aggressive patients ___ Verbally aggressive patients ___ A culture accepting violence as a part of your job ___ The phenomenon of 'nurses eat their young' ___ Relational aggression (horizontal or lateral violence, bullying, or harassment) ___ Changes in your physical health related to nursing (short or long term) ___ Changes in your emotional or mental health related to nursing (short or long term) Del Rio Torres 116 14. What positive influences have you experienced or observed in your work environments? ___ purposefulness ___ welcoming culture ___ supportive environment ___ an involved manager ___ team work ___ kindness ___ outstanding care provided to patients ___ peace ___ knowing you have made a difference ___ positive patient outcomes ___ other please specify ____________________________________ 15. In which of the following activities do you participate in as self care practices? ___ healthy eating ___ exercise ___ rest/sleep ___ pets ___ being in nature ___ friends ___ vacations ___ hobbies ___ prayer/meditating counseling ___ massage ___ family time ___ ___ other please specify _______________________________________ Del Rio Torres 117 Appendix C: Brochure for Participants Del Rio Torres 118 Del Rio Torres 119 Appendix D: Interview Questions What Characteristics are Keeping Nurses Flourishing in Difficult Environments: An Appreciative Inquiry Study Introduction/Warm Up Introduce purpose of interview. Complete Consent and Demographic and Participant Nursing History Survey Main Interview Questions Discover Nursing is a tough, relentless job, what keeps you coming back on shift? What is it about you as a person that lets you continue in nursing? What supports drives you to keep caring for the patients? Dream What is it about the 'heart of nursing' that must be maintained to enable you to flourish as a nurse? (no roadblocks) What would encourage your resilience during the tough times? Design What is it from your nursing education, continuing education, conversations that has brought to life to your nursing? (people struggle with this question) What supports from your employer would promote that resilience? What 'keeps you alive' on the unit that doesn't drain your family life? Deliver How do you take those life-giving factors and impact your 'bubble of influence' on the unit? How might we package this? What ways can we as nurses transform our workplace to create and sustain flourishing nurses? Close of Interview Is there anything else you would like to add? Thank them for participating. Give coffee card. Del Rio Torres 120 Appendix E: Pictorial Diagram on Resilience and Flourishing