A public health approach to understanding resilience during COVID-19

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8 April 2020 

By Sally Amor

The need to respond in real time to the threat of COVID-19 brings unprecedented pressures on each and every person working in the NHS, its partner agencies and within communities. The experiences of health services being relayed from Italy and Spain are sobering at best and run the risk of creating a sense of overwhelm and helplessness.

It is also clear that the impact of COVID-19 will require concerted effort and action over a period of time. It is evident that much work is in hand in this regard and this is a credit to all involved.

While time feels short and the pressure to be ‘doing’ is high, it is understandable that we perceive resilience as being an approach of grit and determination to respond to what is needed in the moment.

However, resilience in the time of COVID-19 might be more usefully thought of as creating environments which can support all involved to negotiate and navigate ways through the complex processes of planning and coordination across whole systems. This needs to be carried out in partnership with communities and with a myriad of staff and, critically, is how we could manage our physical, emotional and spiritual (whatever form this takes) resources to last the long haul.

While time feels short and the pressure to be ‘doing’ is high, it is understandable that we perceive resilience as being an approach of grit and determination... However, resilience in the time of COVID-19 might be more usefully thought of as creating environments which can support all involved to navigate ways through the complex processes 

As is now being understood, leaders, services and communities are planning for a marathon, not a sprint. Rather like the messages in Aesop’s fable, the tortoise and the hare, there is merit in considering how to do the distance, now the initial phase of galvanising action is in hand.

The people in the NHS, its partner agencies and communities are the greatest resource we have when it comes to planning and responding to the demands of COVID-19. Every day, people bring the sum total of themselves to family, work and community life.

We now have a better understanding of how our various life experiences, from the point of conception through to adulthood, shape how we interact with each other and how we respond to life events. It is recognised that adversity and trauma is greater than was previously realised and that this can have a powerful effect on the delivery of care. This is because, when under threat, people may revert to primary survival states of flight, fight or collapse (as seen in supermarket panic buying and hoarding) rather than being able to operate to their full potential, with the capacity for insight, perspective, compassion and empathy. Yet these are the human capabilities that are needed to respond most effectively to COVID-19.

when under threat, people may revert to primary survival states of flight, fight or collapse (as seen in supermarket panic buying and hoarding) rather than being able to operate to their full potential, with the capacity for insight, perspective, compassion and empathy

A trauma-informed and responsive approach seeks to move thinking and responding away from ‘what’s wrong with you?’ to a point of understanding that anger, non-compliance or fear can be a primary response to perceived and real threats. This is best understood as an individual’s ‘Window of Tolerance’.

Providing environments that support people to understand and respond to their own unique window of tolerance creates opportunities for them to acquire the skills to regulate in times of high demand and pressure. The services and personal relationships that help people to navigate their way out of the red zone (feeling over-stimulated or overwhelmed) or the blue zone (feeling sad or lethargic) of their window of tolerance are facilitated by creating safety in relationships that build and create trust.

Through processes of change that look to give individuals choice, people are empowered, increasing the likelihood of them staying within their window of tolerance and offering the potential of building tolerance over time.

The grit and determination commonly associated with resilience can be time-limited and constrained, closer to a reactive survival state rather than a thinking, reflective space that can endure in the long term.

Awareness of the window of tolerance and insights from trauma-informed and responsive systems of care can underpin a dynamic understanding of resilience, seeing it as a resource to be nurtured and developed by individuals and services, both in the moment and over time. The grit and determination commonly associated with resilience can be time-limited and constrained, closer to a reactive survival state rather than a thinking, reflective space that can endure in the long term.

Adopting a trauma-informed and trauma responsive approach to resilience will create a legacy in our immediate response to COVID-19 that will, eventually, underpin recovery and restoration of the day-to-day in times to come.


Sally is a Child Health Commissioner/Public Health Specialist at NHS Highland

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