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April 14, 2020

Cultivating Deliberate Resilience During the Coronavirus Disease 2019 Pandemic

Author Affiliations
  • 1Department of Pediatrics, University of Washington School of Medicine, Seattle
  • 2Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
JAMA Pediatr. Published online April 14, 2020. doi:10.1001/jamapediatrics.2020.1436

Coronavirus disease 2019 (COVID-19) is affecting our health care community in unprecedented ways. As a pediatric oncologist who studies resilience in the context of illness, I started thinking about what this pandemic means for our professional resilience a few weeks ago, when the first US patient with fatal COVID-19 died in my home city of Seattle, Washington.

Promoting resilience among health care workers and organizations starts with understanding what resilience is (and what it is not). Historical psychology and social science suggested resilience was either a trait (eg, hardiness), a process (eg, adaptation), or an outcome (eg, the absence of posttraumatic stress or the presence of posttraumatic growth after a particular adversity).1 The first and last conceptualizations are questionable. The potential for resilience is not a unique trait that one has or does not have; the capacity for resilience is inherent in all people. Resilience is not a single dichotomous outcome measured at a point; we can simultaneously experience posttraumatic stress and growth, and these (and other) outcomes dynamically evolve throughout our lives. Finally, both trait and outcome conceptualizations suggest resilience is something that happens to the fortunate and something we can hope for but not necessarily achieve. This is incorrect. Resilience is neither lucky nor passive. It takes deliberate effort. Indeed, while resilience researchers have quibbled over nuanced definitions and requirements for resilience, they agree that it can be strengthened with practice.1

Modern psychology and social science define resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.”1,2 For years, I questioned the qualification of the word well. Who defines wellness, and what is well enough to meet the threshold of resilience? My questioning stemmed from a conversation I had years ago with a parent who was bereaved. They said they were resilient because they had gotten out of bed that day, because they were putting one foot in front of the other and continuing the hard work of living without their son. I thought, “Yeah. That seems pretty resilient. I’m not sure I would be able to do the same.” I concluded that resilience was about adapting—the wellness part was optional.

Time and observation have forced me to reconsider that conclusion. Certainly, getting out of bed and putting one foot in front of the other is part of the resilience process. But it is not the whole story. If I were to learn that the same parent was still defining their resilience by getting out of bed without some additional forward progress, I would worry. Day-to-day subsisting without wellness is not resilience; it is a failure to thrive. I would wish more for them.

Most people do get to experience more. When they get far enough past an adversity to look back with perspective, they appraise it. They consider its effects on their lives and identities, and (sometimes only with prompting) they reflect on the skills they leveraged or developed, the actions they took, the lessons they learned, and the reasons they kept (or keep) going. The parent who was bereaved and got out of bed each day, for example, recently shared with me that they now endeavor to live their life to the fullest because their son cannot.

What does this mean for us as individuals and organizations in the era of COVID-19? It means we need to be deliberate about navigating the middle of the resilience process, the part between getting through and looking back. Communities and individuals facing adversities as diverse as war, famine, poverty, illness, or death do this by harnessing consistent categories of resilience resources.1,3 Which resources work for whom is highly contextual and based on culture, community, and individual needs. Naming the categories and examples of their corresponding, specific resilience resources helps us identify and harness them.

Categories of resilience resources are individual (eg, personal characteristics and skills), community (eg, social supports and sense of connection), and existential (eg, sense of meaning and purpose; Table). In the context of COVID-19, these apply to both health care professionals and organizations. For example, an individual resilience resource is the ability to successfully set goals, often by identifying and mapping specific, measurable, and realistic steps toward their achievement. For professionals, this may involve the deliberate creation of short-term goals for working from home or for self-care after a stressful day on the hospital ward. For organizations, this may involve deliberately celebrating systems-level steps toward shared community goals, such as evidence that local social distancing practices are beginning to flatten the curve.

Table.  Evidence-Based Categories of Resilience Resources and Possible Applications in the Era of Coronavirus Disease 2019
Evidence-Based Categories of Resilience Resources and Possible Applications in the Era of Coronavirus Disease 2019

Community resilience resources for both professionals and whole organizations may involve deliberate efforts to maintain connections via frequent video conferences and communication of COVID-19 policies and their implications (Table). Finally, to cultivate an existential resilience resource, such as the sense of meaning and purpose, professionals and organizations might deliberately consider the value of their contributions; appreciate experiences, people, and things for which they are grateful; or ground themselves by recalling their missions to help vulnerable populations.

The process of resilience requires these deliberate actions. It is complicated and contextual. It is promotable. The pandemic of COVID-19 has already shown us how dramatically and quickly our world can shift in its approach to population health and individual patient needs. Many of us, as individuals and organizations, are in the beginning phase—the getting-through phase, the one-foot-in-front-of-the-other phase. We can only imagine the end phase, the looking-back phase. We cannot guess exactly what we will have learned. We can only know that none of us will forget.

So, let us now be proactive. Let us imagine our future narrative and direct ourselves toward its end. Let us harness our individual, community, and existential resources so that we not only navigate this experience but also continue to thrive. Let us ensure that when we look back on this story, we will be able to say we adapted well.

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Article Information

Corresponding Author: Abby R. Rosenberg, MD, MS, MA, Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children’s Research Institute, 1900 Ninth Ave, JMB 10-C, Seattle, WA 98101 (abby.rosenberg@seattlechildrens.org).

Published Online: April 14, 2020. doi:10.1001/jamapediatrics.2020.1436

Conflict of Interest Disclosures: Dr Rosenberg is supported by the National Institutes of Health (grants R01 CA222486 and R01 CA225629).

Disclaimer: The opinions presented in this manuscript are Dr Rosenberg’s and do not necessarily represent those of the National Institutes of Health. There are no original data presented in this essay; Dr Rosenberg takes responsibility for the interpretations of published data presented in the references.

References
1.
Southwick  SM, Bonanno  GA, Masten  AS, Panter-Brick  C, Yehuda  R.  Resilience definitions, theory, and challenges: interdisciplinary perspectives.   Eur J Psychotraumatol. 2014;5:5. doi:10.3402/ejpt.v5.25338PubMedGoogle ScholarCrossref
2.
American Psychological Association. Building your resilience. Published February 1, 2020. Accessed March 10, 2020. https://www.apa.org/topics/resilience
3.
Panter-Brick  C, Leckman  JF.  Editorial commentary: resilience in child development—interconnected pathways to wellbeing.   J Child Psychol Psychiatry. 2013;54(4):333-336. doi:10.1111/jcpp.12057PubMedGoogle ScholarCrossref
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    3 Comments for this article
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    Very Useful, Comforting Article
    Marta Rondon, MD | UNIVERSIDAD PERUANA CAYETANO HEREDIA, LIMA PERU
    I think that the most important word in your article is "deliberate", something one chooses to do, even in the face of adversity, trauma, or grief. For an action or a response to be deliberate though, there has to be a choice. The future narrative as you propose it may have several different developments and endings. So, reading you I have gained new insights into the difficulties we face in poorer settings when trying to observe self-isolation: the powerlessness that has been acquired through generations of failure to thrive keeps us from seeing the different narratives! Thanks for sharing your thoughts, I hope what I have learned will help me in my work in these dark days.
    CONFLICT OF INTEREST: None Reported
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    Yes--Resilience is a Skill We Can Cultivate
    David Fessell, MD | University of Michigan
    Thank you Dr. Abby Rosenberg! Yes--resilience has been a field of study for over 50 years. It's very clear that resilience is a skill we can cultivate. Great categories, and yes, we can all help--directly with patients, or in "communities disproportionately affected" by coronavirus--right on! Together we can lift each other up and build our resilience skills.
    CONFLICT OF INTEREST: I have received honoraria for speaking on the topic of resilience.
    Resilience
    Dr Josphat Kagema, PHD | Karatina University, Kenya
    Thank you Prof. Rosenberg for this insightful article exploring the convergence of demystifying resilience in wake of this pandemic. My current research interest is exploring community resilience in Kenya. Thank you.
    CONFLICT OF INTEREST: None Reported
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