Resilience training has become a dirty word in the healthcare industry, but has some useful parallels to help us in selecting, prioritizing, and addressing opportunities to improve quality.


This may sound like raw blasphemy, but there are some useful and positive parallels between resilience training concepts and quality improvement.

However, first some acquired baggage needs to be discussed.


Resilience training has earned a bad name in the healthcare industry, not for any internal faults of the positive psychology movement, or its core methods or ideals, but because of how it has often been proposed as a façade in many healthcare institutions, in which Resilience training has been offered as a solution to clinician burnout.

While individuals may certainly gain from the training, the somewhat cynical proffer was that systemic and institutional dysfunctions leading to clinician burnout could somehow be resolved if only clinicians learned ways to be more resilient. This use of positive psychology as a magician’s cape is unconscionable, but the blame should perhaps not be leveled against Resilience training as such, but against those who should be fixing the systemic issues.

Resilience Approaches

There are several schools of thought, or approaches to Resilience. Dr. Martin Seligman uses the construct of “explanatory style” to describe how each of us has a preferred or default approach to emphasizing and describing the causes of events – be they successes or errors. In Seligman’s approach, a person’s explanatory style has a significant influence on their ability to cope with shocks or burdens, and their eventual life outcomes. Positivity factors endow the individual with significant health benefits, that include quality of life, productivity, and longevity.

In a similar fashion, Seligman’s explanatory style perspective can be used in practical ways to improve care quality. The explanatory style construct breaks into three dimensions, and here we look at each from a QI perspective.

1.    Internal vs External

Don’t focus on the person, but on the process

  • Seligman describes an internal focus as being a key obstacle to optimism, and a cause of stress and burnout. Those who focus on themselves as the cause of problems tend to take insufficient action to address external causes, and as a result see worse outcomes. The worse outcomes may then in turn trigger greater self-blame, and a downward spiral.
  • In QI terms, blaming the individual rather than the process is a key cause of failure. Focusing on the person results in endless cycles of scapegoating, hiding of mistakes and risks, and reoccurrence of errors. The solution is to look beyond the individual person, and identify opportunities to fix process elements that may be due to faulty policies, ineffective equipment, irrational measurements, unsupportive environmental factors, incomplete materials, or poorly-addressed human-factors.

2.    Immutable vs Variable

Focus on the special causes that can be changed, and not on the common causes that will be immune to your efforts

  • Seligman explains that much of people’s attention is often wasted on trying to fix immutable problems, rather than the causes that are amenable to change.
  • Likewise, QI efforts should be prioritized so that resources and opportunities are not wasted on causes that are beyond the control of the team, or which are outside the scope of action. Attempts to fix the unfixable may feel like a just cause for martyrdom, but in practice they yield a poor ROI of effort and time.

3.    Global vs Specific

Unpick a single causal thread, and don’t get sucked into overwhelming complexity

  • Seligman warns that people often catastrophize their problems by seeing everything in their life as being on fire, or at least spreading the flames far beyond the things that need attention.
  • QI encourages us to look at specific cases and to narrow efforts to focus on the causes that are directly related to key elements in the value chain. While many things may indeed need fixing, we should focus on the causes that disrupt the safely, timelines, effectiveness, efficiency, equitability, patient-centeredness, or accessibility of care.


Resilience training courses such as those offered by Dr. Karen Reivich can be of great help in reducing burnout, and likewise, some of its tenets can be used to reduce risks, issues, and missed opportunities in healthcare safety and quality. The three dimensions of the Seligman explanatory style model can be used as part of an effective QI approach.