Learning About Resilience from Rural Interprofessional Healthcare Teams: Insights from the “First Wave” of COVID-19

Introduction

It has long been recognized that healthcare professions face numerous stressors within their clinical practice, including time pressures, workload demands, multiple roles, and emotional issues (including compassion fatigue) (De Hert, 2020). Continued exposure to environmental stressors can seriously impact their physical and mental wellbeing, resulting in burnout and, in some cases, traumatic stress-like symptoms (Arrogante & Zaldivar, 2017). These outcomes can contribute to health professionals experiencing a disproportionately high level of stress related illnesses (De Hert, 2020; Tisdell & Palmer, 2018). Not only is the wellbeing of health professionals affected, but also their ability to practice effectively in caring for others (Golechha et al., 2022). For adult educators who work with and teach these professionals, and for those who work in adult education in a variety of settings, resilience is a key concern (James & Thériault, 2020).

Although pervasive across all health professions, there is evidence that frontline healthcare providers are the most vulnerable to burnout because of their prolonged exposure to stress (De Hert, 2020; O'Sullivan et al., 2020; Zarei et al., 2019). Broadly recognized COVID-19 stressors include adapting to rapid change and new protocols, and making difficult choices to ensure urgent ongoing public health problems are addressed, while minimizing risk to health professionals, their families, and communities (Lu et al., 2020). Before COVID-19 in the spring of 2020, the prevalence of severe burnout among Canadian physicians, nurses, and other healthcare professionals was 30%–40%; by spring 2021 these rates were greater than 60% (Maunder et al., 2021). A recent survey by the Ontario Nurses Association (2022) indicates over 75% of Canada's nurses are burnt out, with many leaving their profession or retiring due to unacceptable working conditions.

Considering that resilience may be an important protective factor against deteriorating psychological responses to the pandemic, researchers have been examining the resilience of frontline healthcare providers across COVID-19 (Baskin & Bartlett, 2021; Golechha et al., 2022; Grailey et al., 2021; Huffman et al., 2021). Basic needs such as sleep, life satisfaction, and psychological resilience as determinants of quality of life have been significantly tested as these professionals respond to the pandemic (Bazdag & Ergun, 2021). Yet, much of this research focuses on acute care settings (emergency, intensive care, etc.) in urban and metropolitan settings (De Hert, 2020; Golechha et al., 2022). Less is known about rural primary healthcare settings, which are recognized to have entered the pandemic “already chronically underserviced, facing inadequate health care infrastructure, with limited clinical resources, and equipment and health care personnel shortages” (O'Sullivan et al., 2020, p. 1188). These researchers make the case that when rural risks and needs are overlooked as part of the overall mainstream pandemic planning, the potential for burnout is significant and threatens the overall rural resilience. This exacerbates social and economic inequality in rural settings.

This case study explores the lived experience of some of these healthcare professionals during the “first wave” of COVID-19 (March 2020–October 2021). The context is primary healthcare, the area of healthcare that focuses on frontline healthcare services, including the diagnosis and treatment of illness and injury (WHO, 2010). Those who work in primary healthcare, often referred to as “primary providers,” are involved in direct provision of first contact healthcare services (e.g., physicians, nurse practitioners, pharmacists). Within a primary healthcare model of service delivery, different healthcare professionals with diverse knowledge, skills, and talents work together (interprofessionally) in “collaborative practice teams” to improve access to care by putting patients in front of the right healthcare professionals at the right time (WHO, 2010).

Although many other primary healthcare professionals work in rural contexts in Nova Scotia (family practice physicians, pharmacists, nurses, dieticians, etc.), these rural interprofessional teams are of particular interest. They have long been recognized to improve communication, save time, reduce duplication of effort, improve working relationships, and provide a better experience for people who use health and social care services (Bosch & Mansell, 2015). Recent COVID-19 research suggests they are ideally equipped to support populations at greatest risk of adverse health outcomes during pandemics, including older adults and patients with chronic physical and mental health conditions (Donnelly et al., 2021), who generally populate rural settings.

These teams are also a hallmark of the collaborative care model of service delivery launched in Nova Scotia in 2008 to strengthen and increase access to primary healthcare, particularly in rural communities, where challenges in accessing healthcare (demographics, geography, access to providers, etc.) are an enduring reality (Nova Scotia Health Authority, 2017). Since 2008, more than 90 interprofessional collaborative practice teams have been launched in rural Nova Scotia. Similar interprofessional team models have been established and evaluated across Canada, including primary care networks in Alberta, local community service centers in Quebec, and nurse practitioner led clinics in Northern Ontario (Aggarwal, 2022). Their common link is increasing access to healthcare in rural settings. Yet, little is known about how these teams learn to cope with the stress of limited resources and major traumas, such as the pandemic, or about how this learning is best supported. Resilience in healthcare is important because it enables the delivery of quality care. In the context of COVID-19, prioritizing the physical and mental wellbeing of the healthcare workforce is an important step in assuring quality healthcare outcomes.

The Health Resilience Context

The resilience of a health system refers to its “capacity to anticipate and respond to shocks, such as public health emergencies, in an adaptive manner that includes appropriate action against the shock and optimal maintenance of routine core functions” (Haldane et al., 2021, p. 7). Further, systemic resilience has two components: organizational resilience and individual resilience. Organizational resilience exists at multiple levels. It can be situated involving anticipation, adjustment, and learning during care delivery (Wiig et al., 2020), or it can be structural involving strategy and planning that delivers resilience, such as performance monitoring, emergency response planning and workforce planning (Ignatowicz et al., 2023). Individual resilience, the second component of systemic resilience, concerns a healthcare worker's ability to “withstand pressure imposed by an emergent situation without compromise to quality of care, or their own health and wellbeing” (Huffman et al., 2021, p. 278). A resilient individual is recognized to “thrive in the face of adversity, cope effectively with stress, and maintain stable psychological functioning” (Huffman et al., 2021, p. 284). Learning to cope in such extreme conditions is a challenge to vulnerable adults in multiple situations (English & Mayo, 2021).

Burnout results when individual resilience is failing or exhausted. It is defined by Gregory et al. (2018) as an individual's unique “stress reaction to the workplace, characterized by emotional exhaustion, depersonalization, and reduced self-efficacy” (p. 338). Burnout is a complex phenomenon characterized by the interpersonal relationship among the provider, the service user, and the healthcare organization (Newell, 2017). Yet, despite this theory that burnout involves some breakdown in the relationship between the employee and their workplace, interventions have generally focused on building the individual's resilience to “withstand this imbalance rather than identifying and ameliorating the cause” (Gregory et al., 2018, p. 338). They argue that those in the organizational leadership need to look beyond the outcome of interventions aimed at improving individual self-care—especially if the individual is not able to effect changes to the environmental conditions that precipitated burnout in the first place.

In fact, proponents of resilient thinking have long recognized that for sustainable system change, action must be taken at several levels (i.e., organizational and individual) if overall system-level resilience is to be secured (Robertson et al., 2016; Skovholt & Trotter-Matheson, 2016). COVID-19 researchers agree such whole system approaches—those that combine organizational-directed interventions with workplace support interventions (e.g., counseling, training) that enhance staff wellbeing—offer the greatest potential to reduce occupational stress and burnout and to build the foundational resilience that enables health professionals to navigate pandemics and other unexpected adverse conditions (De Hert, 2020; Johnson et al., 2020; Rieckert et al., 2021).

The Health and Learning Context

Those of us who teach or work directly with health professionals working on the front lines are reminded daily of their educational challenges, the conditions in which they work, and the impact on their lives. How to encourage learning to be resilient is a concern for many of us in continuing professional education as we observe the “chaotic conditions where interconnected and interdependent professionals toil to handle relentless change and ambiguity” (Bierema, 2018, p. 27). As adult educators, we understand the strong, mutually reinforcing relationship between education and health, where improvements in one have a clear positive impact on the other (English & McKay, 2022). As such, we have long argued that resilience learning should be part of the educational content of a health professional's pre-service education and continuing professional education, and it should be taught in a way that promotes reflection and application to foster strength, focus, and endurance in the workplace (McAllister & MacKinnon, 2009; McCann et al., 2013). Yet prior to the pandemic, a consensus remained among educational scholars that, overall, the education of health professionals had not adequately supported this learning or “addressed the issue of self-care and coping with stress, burnout, and compassion fatigue so prevalent in health systems” (Tisdell & Palmer, 2018, p. 21). As Tisdell and Palmer (2018) observed, “a high emotional intelligence among health care providers is more positively correlated with quality of health care; hence its cultivation among health care workers is desirable” (p. 22).

COVID-19 has provided a more recent opportunity to study resilience and to examine ways to increase resilience. As such, educational scholars are now examining not only the impact of COVID-19 on adult learning and education in health contexts, including rural health contexts (O'Sullivan et al., 2020), but also the continuing professional education supports that can foster resilience and wellbeing among primary healthcare professionals (Donnelly et al., 2021). The voices of the participants in this study provide a starting point in understanding how individuals learn, grow, and develop resilience in light of traumas or challenges such as the pandemic. Given that most studies of resilience in healthcare are frequently tightly focused on individual learning, with only limited focus on team learning (Haraldseid-Drifland et al., 2022), the lived experience of these teams can provide insights on how collaborative learning occuring in everyday team practice might translate into resilient performance and an ability to handle unforeseen adverse events. This paper is intended to add to adult education and lifelong learning literature focusing on the interrelatedness of healthcare, continuing professional education (CPE), and transformative learning.

Methodology and Research Context

An exploratory case study provided the methodology for orienting this study. Data collection involved three focus group interviews with rural collaborative practice teams in a single health district in Nova Scotia, Canada the fall of 2021. Each focus group had five or more participants. Teams were physician-led and populated by allied health professionals (e.g., nurses, dieticians, physiotherapists, administrators), making the teams homogeneous in composition. In total, the study involved 18 participants. They were all well-educated for their professional roles, and the span of ages was 30–60 with the average age being 45. They were 60% female and 40% male. Except for three members of one team, all others were English first language speakers, and all were Caucasian, representing the local population mix. Though located in three separate communities, participants were all in the same geographic area of the province, which is predominantly white, rural, with a lower socio-economic status. It should be noted that this research focuses on the first year of COVID-19 (March 2020-October 2021), often referred to as the “first wave” of the pandemic, when Nova Scotia had very low case counts due to strict provincial public health measures and a COVID-Zero strategy in Atlantic Canada. Team accounts revealed many commonly shared and interrelated experiences, with only subtle differences in the overall experience. It is these commonly shared experiences and responses to COVID-19 that are the focus of the next section of this paper. In this next section, individual team member affiliation is noted by Team 1, Team 2, and Team 3.

Team Experience and Learning

The lived experience of resilience in healthcare workers is shaped by many personal, interpersonal, and work-related factors (Brown et al., 2021). A framework developed by Grailey et al. (2021) to explore the lived experiences of healthcare workers on the front line during the first wave of COVID-19 is adapted here to profile emergent themes in this study, including (a) changes in workplace stressors; (b) changes in psychological safety; and (c) changes in team dynamics and innovation. Like the Grailey et al. (2021) study, the timeframe of this study spanned the ‘first wave’ of the COVID-19 pandemic, similarly revealing the impact of the pandemic on these factors, but in a rural interprofessional team setting. Verbatim quotes are included in the next section of this paper to bring these teams’ shared experience and ideas more vividly to life.

Summary and Conclusion

The purpose of the study was to learn about the lived experience of rural interprofessional collaborative teams across the first year of the pandemic as a basis for understanding how resilience learning might be nurtured and supported in rural team-based collaborative practice settings. The study reveals the teams experienced psychological distress and mental exhaustion. Initially, they felt challenged to cope with an increased workload, fear of the disease, and uncertainty about system-level communication and support. In this regard, their experiences resonate with most frontline providers in the first year of COVID-19. Yet, while the challenging demographics and historic patterns of inequitable resourcing of rural health were acknowledged, such as limited clinical resources and staff shortages (O'Sullivan et al., 2020; Petrie et al., 2021), no pandemic related workplace stressors specific to their rural contexts were identified.

Rather, despite these recognized rural challenges and pandemic related occupational stressors and risk factors, a significant level of collective resilience, defined by Delgado et al. (2021) as a “shared identity and capacity arising within a group that enables them to draw on their collective sources of support, to deal with adversity” (p. 376), was apparent in the accounts of the teams. For these teams, a history of working together and stepping up to help each other with tasks contributed to a sense of ‘banding together’ that enabled them to move beyond disorientation and shock to action and innovation in response to the pandemic. It has been noted that a critical source of collective resilience in emergencies and disasters is the trend to come together psychologically and behaviorally (Delgado et al., 2021; Jordan et al., 2022).

The relatively rapid pace with which all three teams were able to adapt and direct their responses—what Susan referred to as thinking and working “outside the box, and yet, within the boxes of the COVID protocols”—is evidence of an adaptive capacity. This adaptive capacity which enabled these teams to anticipate and respond to the pandemic can be linked to the integral knowledge they had of their rural communities and cultures and recognition of people and organizations as health assets (Lesperance et al., 2022). For example, as part of their pandemic response, teams leveraged the help of patients, community cultural groups, officials, and local radio and television stations to safely disseminate pandemic information and vaccine rollouts. Their adaptive capacity can also be linked to the team's structure and history of collective dialogue, problem-solving, and interprofessional collaboration. They had learned to value each other's expertise, to realize a good idea when they saw it, and to rapidly implement new ideas into practice.

Rural health researchers describe this ability of healthcare teams to build and draw on their collective knowledge of what is possible and to quickly evaluate options in terms of their fit for the needs of a community, as an absorptive capacity (Petrie et al., 2021). Drawing on their individual and shared knowledge, these teams were able to absorb new information and priorities (centrally mandated initiatives), to act somewhat autonomously, and to innovate in the face of overall system stress. This capacity for locally diverse action, that does not reduce access to care or quality of care, has long been recognized as a hallmark of a socially responsive and community-based approach to care (O'Sullivan et al., 2020)

Underlying the resilient performance demonstrated by these teams across the first wave of the pandemic was a significant level of continuous learning that advanced their adaptive and absorptive capacity. Learning how to navigate the pandemic mimicked their everyday collaborative work processes and contributed to a shared understanding of how to respond to the new and uncertain challenges they faced. The ability to adapt was not just dependent on individual actions, but on their collective learning and their shared contextual knowledge. Valerie's insights on the nimbleness and flexibility of her team suggest that her individual resilience was learned and enabled by being part of her team, and she drew strength and resilience from the team's collective learning and action. Trust, dialogue, and communication became central tools in leveraging their collective resilience, enabling these teams to cope, to adapt to a new normal state in response to the disruption, and to return to some ‘normal’ condition or transformed state of functioning without compromising system performance (Wiig et al., 2020).

As learning emerges as a key enabler of resilient action in this study, continuing education strategies to support resilience leaning are important to consider. The findings of this study reinforce that collaborative learning occurring through interactions with others through work practices, such as teamwork and problem-solving, contributed to their resilient performance. According to Wiig et al. (2020), these kinds of local adaptations, incremental learning, and transformations happen in everyday interactions and work practices in healthcare, without anyone necessarily knowing. In this study, teams demonstrated collective resilience developed from continuous learning that served as a foundation in their early response to the pandemic. The synergistic interplay between personal, relational, and organizational (team) factors further strengthened their learning and collective resilience, enabling them not only to respond to the pandemic, but to transform individual, interactive, and organizational practices. This ability to enact adaptations and address the changes while continuing to deliver a quality service is evidence of growing resilience and transformative learning in action (Romano et al., 2022).

Adult educators can play a key role in supporting this kind of practice-based learning by developing collaborative tools and processes that foster awareness and dialogue that lead to a shared understanding of how to navigate unexpected challenges and adversity. For example, a community of practice (CoP) is an important continuing professional education strategy that could offer an accessible way for healthcare workers who interact regularly to improve the quality of care through learning and knowledge sharing. As is reinforced in this study, in collective supportive spaces, individuals can share experiences, teams can collectively and critically reflect on adverse situations, raise new questions regarding how to face adverse and unexpected situations in the future, and expose and talk about vulnerability as a shared experience (Delgado et al., 2021). Such critically reflective spaces, tools, and processes are recognized to support the development of both active and passive resilience. Active resilience is the process of actively engaging with stressors and using them as opportunities for growth and learning. Passive resilience relates to the ability to ‘bounce back’ and get back to normal procedures after an adaptive change has happened “without any further development of skills or systems” (Wiig et al., 2020, p. 3).

According to Haraldseid-Driftland et al. (2022), a resilient organization is one that recognizes that “the ability to adapt and respond to challenges and changes relates to the ability to both work and learn, collaboratively, which enables healthcare professionals to actively develop a shared understanding and provide quality care” (p. 2). Adult educators can support the efforts of health systems to create a supportive learning culture, where practitioners can develop these mutually supportive relationships to learn and grow together through their collaborative practice experiences. As this study reveals, it is this shared collective identity and capacity arising within a group or organization that enables its members to draw on its collective sources of support to deal with adversity (Delgado et al., 2021). The shared values and culture of ongoing collective learning had a significant impact on how these teams went about their everyday practice. Interprofessional learning was ongoing and supported by building trusting relationships and having shared values that contributed to their ability to adapt and to regain equilibrium in circumstances of change.

Findings from this study reinforce the extent to which collaborative learning enhances an individual's capacity for resilient performance. At the same time, resilience researchers Haraldseid-Driftland et al. (2022) view individual action as an indirect reflection of systemic resilience and suggest that efforts to strengthen resilience in healthcare must take a systems perspective that enables teams, or units, to collaborate to learn how to adapt to their changing circumstances. In addition to intentional educational activities (e.g., seminars or simulation activities), these researchers encourage the creation of spaces for reflection and awareness, through activities of daily work, as a mechanism for supporting individual, team, and organizational learning that contributes to systemic resilience. Obviously continuing professional education strategies of this kind would require supportive time and space within practice environments and the involvement of all team members to allow for divergent experiences and ideas in the group.

Findings from this study reinforce the value of a whole system approach to fostering resilience in healthcare—one that combines organizational-directed interventions to change workplace factors which create stress, with workplace support interventions (e.g., counselling, training) to enhance staff wellbeing. As established earlier, this approach offers the greatest potential to reduce occupational stress and burnout and to build strong systemic resilience, which enables health professionals and teams to navigate disruptive and unexpected adverse conditions.

Adult educators can be instrumental in supporting healthcare systems in these efforts to strengthen their ability for resilient performance. Because resilience can be mobilized before, during, or after a disturbance (Wigg et al., 2020), adult educators can begin by assessing existing levels of individual and organizational resilience. Given the high level of interdependence among healthcare professionals and other healthcare stakeholders, efforts by adult educators to support resilience learning might best be undertaken in group contexts, where health professionals who work together also learn together. Adult educators can develop continuing professional education strategies that can aid healthcare organizations to support the process of collective learning and change and can support organizational efforts at remaking or transforming individual, interactive, or organizational policies and practices that can assure resilient action and quality healthcare.

As adult educators, we can be attentive to these positive findings and can also question if these findings would be consistent with a broader sampling of interprofessional collaborative practice teams in different settings, possibly urban areas, and with other groups of healthcare providers. A systems perspective of resilience demands collaboration and learning within and across healthcare system levels. As educational researchers we can study the interactions of daily collaborative work in healthcare which are generative of learning and changes in practice. In understanding the underlying learning processes of how and why collaborations occur, we are better able to support the process of collective learning and change that contributes to individual, organizational, and systemic resilience. Learning for resilience is not a well-researched topic in adult education and health and will need much more attention and consideration, given the increasing complexity of modern life and healthcare. Further attention and study of the links between health and learning are also needed, as pandemics are not over, and healthcare is continuously challenged.