,. --., ' A/r/tography: A Living Inquiry into Resilience Barbara Robinson A thesis submitted to The Faculty of Graduate Studies in partial fulfillment of the requirements for the degree of Masters of Science in Nursing Graduate Program in Nursing York University Toronto, Ontario June 2013 ©Barbara Robinson, 2013 ii Abstract This qualitative action research used a/r/tography, an arts-based process that involves the creation of art and text in a living inquiry to explore how nurses understand and describe the concept of resilience. Meanings and understandings about resilience emerged from the community of inquiry with participants who encompassed the roles of artists/researchers/teachers. The renderings (contiguity, a living inquiry, metaphors and metonymies, openings, reverberations, and excess) are concepts of the research method with related questions that guided the group to explore resilience. Discussions included stories and images of resilience that generated recurrent themes. Analysis identified the themes of resilience for research participants: connecting an,d reconnecting,· living the questions,· and seeing with new eyes. Implications of the new understandings ofresilience for education, practice, and additional ·research are also considered. iii Dedication This research is dedicated to my dear husband Sean whose love, dedication, and unwavering support is more valuable than words could ever express. You were with me '~very step of the way as I pursued my dream of graduate education. I could never have completed this work without you. To our three wonderful children, Monica, Michael, and Michelle, you never missed an opportunity to express delight in my modest accomplishments. Your own educational achievements and passion for learning have tremendously motivated me in my own studies. iv Acknowledgements I would like to express my heartfelt thanks to Dr. Gail Mitchell, my supervisor. Your brilliant work has been an inspiration and source of rejuvenation for me in my nursing practice and in my life for many years. Your creativity and innovation are unparalleled, and as a result my learning has been rich and diverse. I am deeply appreciative of ~he significant amount of time and energy that you have so willingly shared. I would like to express my profound gratitude to Dr. Christine Jonas-Simpson, also a member of my Supervisory Committee. Your willingness to embrace new ideas is a testament to your progressive and enlightened thinking. Your sincere interest and responsiveness has made this work possible. I have been so fortunate to benefit from your knowledge and wisdom. Finally, I am indebted to each and every participant in my research project. You were courageous enough to commit to being part of a novel and intriguing process of research without hesitation. We shared a life-altering experience that no one will ever forget, and I am so grateful. v Table of Contents Abstract ............................................................................................................................. ii Dedication ........................................................................................................................ iii Acknowledgements .......................................................................................................... iv Table of Contents .............................................................................................................. v Chapter 1 : Introduction ..................................................................................................... 1 A/r/tography: A Living Inquiry into Resilience .................................................... 1 Significance of the Study ...................................................................................... 1 Purpose of the Study ............................................................................................. 3 Research Question ................................................................................................ 3 Chapter 2: Review of the Literature ................................................................ ~ ................. 4 Chapter 3: Research Methods ........................................................................................... 8 Philosophical Underpinnings of the A/r/tography Method ................................... 8 Research Design .................................. :. ................................................................ 9 Ethics and Participant Selection .......................................................................... 12 Data Collection ................................................................................................... 15 Data Management and Analysis ................................................ ~ ........................ 17 Chapter 4: Description of Findings and Data Gathering Process of Discovery ............. 19 The Renderings .................................................................................................... 19 Contiguity ............................................................................................... 19 - A Living Inquiry ..................................................................................... 21 Metaphors and Metonymies .................................................................... 25 Openings ................................................................................................. 26 Reverberations ........................................................................................ 27 Excess ..................................................................................................... 29 Chapter 5: Presentation of Findings ................................................................................ 32 Thematic Analysis ............................................................................................... 3 2 Connecting and Re-Connecting .............................................................. 32 Living the Questions ............................................................................... 41 Seeing With New Eyes ........................................................................... 52 vi Chapter 6: Discussion of Findings .................................................................................. 61 Discussion of the Renderings and Themes ......................................................... 61 Connecting and Re-Connecting .............................................................. 61 Living the Questions ............................................................................... 66 Seeing With New Eyes ........................................................................... 71 The Process of A/r/tography ............................................................................... 73 Chapter 7: Conclusions ................................................................................................... 85 Recommendations for Education ........................................................................ 85 Recommendations for Practice ........................................................................... 88 Recommendations for Research .......................................................................... 89 Dissemination ..................................................................................................... 91 References ....................................................................................................................... 93 Appendices .................................................................................................................... 101 Appendix A: Ethics Approval York University ................................................ 101 Appendix B: Ethics Approval Queen's University ........................................... 103 Appendix C: Demographic Data Form ............................................................. 105 Appendix D: Demographic Data Information .................................................. 106 Appendix E: Flyer Advertising A/r/tography Research Project ....................... 109 Appendix F: Informed Consent Form ............................................................... 110 Appendix G: Sample Questions ........................................................................ 113 Appendix H: Poem Session #2 ......................................................................... 115 List of Tables ................................................................................................................ 106 Table Dl: Participants' Age .............................................................................. 106 Table D2: Participants' Marital Status .............................................................. 106 Table D3: Participants' Education .................................................................... 107 Table D4: Participants' Income ........................................................................ 107 Table D5: Participants' Religious Affiliation ................................................... 108 Table D6: Participants' Race ............................................................................ 108 Table D7: Participants' Ethno-Cultural Heritage .................................................. 1 "' 1 Chapter 1: Introduction A/r/tography: A Living Inquiry in1to ResUience Most persons experience challenges and stress in day-to-day life and work. Personal strategies and abilities to manage stress while continuing to thrive are of interest to many scholars and practitioners. Resilience has been identified as a concept that can help to conceptualize the interplay of stress and wellness (McAllister & McKinnon, 2008). This study will look at this interplay of stress and wellness through an arts-based 1 research method with nurses working in a multi-site organization that provides specialized mental health care, physical medicine and rehabilitation, specialized geriatric services, complex continuing care, palliative care and long-term care. Significance of the Study In general, nursing work, especially in acute care settings, has been described as very stressful (Grafton, Gillespie, & Henderson, 2010; Horgam;Lightfoot, Lariviere, & Jacklin, 2013; McGibbon, Peter, & Gallop, 2010). Representing the largest occupational group in healthcare within Canada (Shields & Wilkins, 2005), nurses have been the subjects of a great deal of research on workplace stress. A projected shortage of nurses was identified decade ago and position papers examined issues of work life, including workplace stress, in order to make recommendations to professional bodies and policy makers (Canadian Health Services Research Foundation [CHSRF], 2006). Findings supported the idea that working to minimize perceived stress levels of nurses resulted in improved patient outcomes including both well-being and safety (Armstrong, Laschinger, 1 It is not my intent to essentialize or suggest that nurses are a homogenous group. To be a nurse is to enter a role and regime that is historically and geographically situated. 2 & Wong, 2008; McGillis-Hall, Doran, & Pink, 2008). The (Canadian) National Survey of the Work and Health of Nurses (Shields & Wilkins, 2005) also confirmed the link between the most tension-producing elements of nursing work and their negative effects on nurses' mental and physical health. Clearly, improving the quality of work life for nurses enhances nurses' health as well as patient outcomes, both of which support the sustainability of the healthcare system as a whole (Horgan, Lightfoot, Lariviere, & Jacklin, 2013). In light of the reality that stress is a significant issue for nurses, the concept of resilience emerges as an important phenomenon for study. Resilience has traditionally been viewed as the ability to recover from acute or chronic stress and return to homeostasis, despite the experience of adversity. Primarily, resilience has been viewed as an individual trait (Herrman et al., 2011; Jackson, Firtko, & Edenborough, 2007). However, more recently a broader view of resilience that enc0mpasses interactions between persons and their environment has been proposed (Unger, 2012). This concept that Unger (2012) calls "social ecology", asserts that environrpents may be more influential on resilience than individual capacities. Research related to stressful healthcare environments that examines the process of resilience is just beginning (McAllister & McKinnon, 2008). There is more to learn to be able to support nurses in developing and sustaining resilience. This study presents the arts-based approach called a/r/tography that was used with a group of nurses to explore the understanding of resilience. 3 Purpose of the Study The purpose of this research was to explore how nurses understand and describe the concept of resilience. The researcher used an arts-informed method called a/r/tography to engage with nurses in an inquiry of resilience. Arts-based research methods provide the opportunity to seek meaning and make new connections between thoughts, often enabling ideas to surface that would not be evident in more traditional research methodologies (Springgay, Irwin, & Kind, 2005). A/r/tography is a methodology of embodiment, referred to as a "living inquiry" (p. 899). Reflections about personal experiences occur in art-making processes that are grounded in text. It is anticipated that findings from the a/r/tography will enable nurses and other healthcare professionals to become more knowledgeable about ways to enhance resilience. (Armstrong, Laschinger, & Wong, 2008). Research Question The research question that guided this study is "What·.is the understanding of resilience for nurses?" 4 Chapter 2: Review of the Literature There are various definitions of resilience in the literature, and a gradual progression in the meaning of the concept over time. I used CINAHL, ERIC, and Scholar's Portal with the terms a/r/tography, arts-based research, nurse(s), and resilience to develop the literature review for the proposed study. I also utilized the ancestry approach of obtaining references from relevant articles. In the 1970s the foci of published research on resilience was to determine what individual traits or personality the term resilience, such as flexibility, fortitude, and the presence of a creative vitality despite adversity (Grafton, Gillespie, & Henderson, 2010). Resilience was also viewed from a physiological perspective with homeostasis being the goal, or a psychological perspective that included the ability to move beyond stressful experiences in a positive way (Jackson, Firtko, & Edenborogh, 2007). While many in the realm of psychology continued to focus on strengthening the individual, the influence of critical social theory researchers raised new and important issues related to resilience and the context of relations and resources. Our human differences in flexibility and inner fortitude are many, and the social determinants of health directly influence our ability to be resilient. Unger (2012) describes a more recent, comprehensive view of resilience that encompasses a group of interrelated environmental or ecological factors. Unger suggests that these ecological factors may predict the ability to be resilient more than individual differences and traits. The broader perspective deepens understanding and further contextualizes the meaning of resilience, shifting thinking from individual traits to an interactive, person-environment connection. Although much of the research about