this, the transition from the classroom to the uncertainties of clinical practice can engender feelings of being unable to cope and not being good enough. Often referred to as ‘imposter syndrome’, Gottlieb et al. found rates of 22–60% in physicians and physicians in training (see Chapter 4). Gender, low self‐esteem and institutional culture are risk factors, while social support, validation of success, positive affirmation and personal and shared reflections were protective (Gottlieb et al., 2020). Feeling unsupported as we make our first clinical decisions can only exacerbate further feelings of being a fraud. Imposter syndrome is associated with increased risk of burnout and suicide.
Our patients require us to be cognitively ‘at the top of our game’ during every encounter. Diagnostic error is unfortunately common, and faulty cognition is a contributor to this. Evidence from neuroscience increasingly supports a link between our mood and cognition. This was recognised not only in the context of mental health but increasingly in the context of clinical reasoning. We discuss this in Chapter 3.
In addressing our cognitive performance, we need to consider our ‘career cycle’ (see Chapter 4). Our physical and mental abilities change over a working lifetime. In addition, our knowledge base and clinical experience change over time. There are transitions during our career (promotions, learning new procedures, complaints, personal life events) when our resilience may be more challenged and our propensity to burnout increased (Puddester et al., 2009). During these times, our likelihood of making a major mistake rises. Chapter 4 discusses these phases and strategies for coping with them.
Since the 1960s, heart rate variability (HRV) has been recognised as part of the stress response. For example, patients with depression have reduced HRV. Our stress response, of which HRV is part, evolved over thousands of years and for a different stress landscape. Change, including in healthcare, proceeds at an increasingly rapid pace, and we have not necessarily adapted to this. Many healthcare workers report practicing in a state of constant stress (NHS England, 2018). In turn, our cognitive performance and clinical decision‐making is impaired. In Chapter 5, we outline the physiology of well‐being.
John Donne’s assertion of our being ‘involved in mankind’ suggests that a connection or kinship with others should be mutually beneficial for all – as Donne also wrote, ‘No man is an island’.
There is a responsibility to be cooperative with others in return for a right to receive cooperation and support from others. This is an affirmation of life and is reflected in the quality our relationships with our patients and colleagues. I, as an individual, my patients, my colleagues, my employer and regulator are all involved in mankind and connected to one another. In healthcare, as in life, we can achieve more for our patients through cooperation. Our singular well‐being is dependent on our working together and only brought into being by our ‘intelligent kindness’ towards one another. This is considered at length in Chapter 6.
The individual practitioner cannot be resilient alone, and so we have to consider the role of teams on patient care and staff resilience. Riskin et al. demonstrated the effect of rudeness in healthcare teams and of a culture of rudeness in the working environment, both on procedural tasks and, even more so, on the communication tasks which underpin good clinical decision‐making and effective patient treatment (Riskin et al., 2015). Kindness to patients improves their health outcomes. Kindness to each other improves patient safety. Organisational kindness results in resilient professionals in a safer environment with better patient outcomes. It is a virtuous circle. We discuss this further in Chapters 7 and 8. Chapter 9 looks at resilience in practice and how approaches such as the ‘most respectful interpretation’ in assessing the motivation and intentions of others can be transformative in the relationships of healthcare professionals both with each other and with our patients.
Equality, diversity and inclusion in healthcare resilience
We cannot consider practitioner resilience and its relationship to patient safety without acknowledging that our lofty proclamations of equality for all is far away from the lived experience of many of our colleagues. For example, in the UK National Health Service (NHS), there is a significantly higher percentage of black, Asian, minority ethnic (BAME) workers than in the general population (21% versus 13.8%). In London, while 43% of the NHS workforce is from BAME backgrounds, they occupy only 14% of board‐level positions in local healthcare (Kings Fund, 2018).
Staff experiences include the following:
‘…patients really can be difficult. I mean, recently I had a patient who told me that I was the wrong colour to be English’
(Kings Fund, 2019)
While initiatives such as the British Medical Association’s Equality Matters campaign and the BMA Charter on Racism in Medicine have sought to address this, the extent of the problem was brought into sharper focus during the 2020 pandemic, when it emerged that the death rate among BAME healthcare workers was disproportionately higher than non‐BAME practitioners (Box 1.2). This was a tragedy set against the backdrop of a health service which would collapse without BAME staff.
There is evidence that BAME staff struggled more to obtain adequate PPE as compared to their white counterparts (Box 1.3). Nowhere was this more tragically illustrated than in the case of Abdul Mabud Choudhry (Box 1.4).
Box 1.2 Proportion of Covid‐19 related death in UK healthcare workers from BAME background.
UK healthcare workers from BAME background have been disproportionately affected by the Covid‐19 pandemic. This is manifested by increased death rates across groups of healthcare workers:
21% of all healthcare workers are BAME.
63% of healthcare workers who have died were BAME.
20% of nursing staff are BAME.
64% of nurses who died were BAME.
44% of medical staff are BAME.
95% of doctors who died were BAME.
Source: Adapted from HSJ Survey (2020).
Box 1.3 Access to personal protective equipment (PPE) in UK healthcare workers from BAME background.
A survey published by the Royal College of Nursing on 28 May 2020 found that BAME‐category nursing staff were more likely to have difficulty accessing adequate PPE during the Covid‐19 pandemic:
43% of BAME staff had enough eye and face protection, as compared to 66% of white British nursing staff.
37%
