Grit Makes Us Unstoppable

The incoming President’s theme at the American Association of Critical-Care Nurses (AACN) 2019 National Teaching Institute (NTI) was “Unstoppable.” In the President-Elect’s keynote address on May 22, 2019, at NTI,¹  Megan Brunson talked about nursing colleagues who demonstrate grit, and the importance of grit in being unstoppable.

Grit is a personality characteristic that psychologist Dr Angela Duckworth and colleagues²  described in 2007 as having 2 components: passion and perseverance. Passion involves a consistency of interest over time and commitment to long-term goals; perseverance involves a steadfastness and dedication to working toward those goals over time. In a recent TED talk, Duckworth describes perseverance as “living life like it’s a marathon, not a sprint.”³  Duckworth’s research in a variety of educational and occupational settings demonstrated that grittier people outperformed less gritty people, regardless of intelligence level. People with grit are unstoppable because they are passionate about their long-term goals and persistent in achieving them.

Grit is difficult to study, and research about it as a psychological construct is still developing.⁴  Most of the research about grit relies on participants’ self-report, using instruments developed by Duckworth and colleagues. The Grit Scale is a 12-item self-report questionnaire that measures both consistency of interests (passion) and perseverance of effort.²  A short form of the instrument (Grit-S) with fewer items but better psychometric properties was developed in 2009.⁵ 

Grit has been the subject of a few investigations of students in health professions.⁶  Among 702 pharmacy students, grit was a significant and independent predictor of academic performance.⁷  In a study of undergraduate nursing students, researchers found statistically significant positive associations between grit and both course engagement and skill development.⁶  Higher grit in medical students was a predictor of better academic performance as well.⁸  Interestingly, these studies suggest that grittier students have both better clinical knowledge and better clinical skills than their less gritty counterparts, and these differences are more related to personality than to native intelligence.

Although the influence of grit on performance of practicing clinicians has not yet been thoroughly examined, we think 2 tantalizing published studies are important to highlight. In a study of 240 front-line therapists treating patients with substance use disorder, Patterson Silver Wolf and colleagues found that therapists with higher grit scores also had higher therapeutic alliance scores (a measure of therapist clinical skill).⁹  Perhaps more intriguing, therapists with higher grit scores were more positively inclined to implement evidence-based interventions (EBIs) than were therapists with lower grit scores. The researchers concluded, “Grittier therapists may better align with their patients, and are more open, willing, and able to implement EBIs, while also being less likely to diverge from those EBI protocols.”^9(p963) In a study of 400 nurse leaders in the United States, Seguin found that grit was associated with both higher educational attainment and lower scores for burnout; the nurse leaders with higher grit scores were also lifelong learners.¹⁰  These 2 studies are not definitive, and none of the participants were critical care clinicians; furthermore, studies to date have examined outcomes only in health professionals and have not linked patient or family outcomes to provider grittiness. We look forward to additional research about grit focused specifically on clinical providers in critical care, and we wonder whether grit may influence provider knowledge and skills, therapeutic relationships, use of EBIs, lifelong learning, and—potentially—patient outcomes.

Grit may be an important characteristic for researchers as well as clinicians. The acute care setting during critical illness is a challenging environment to conduct high-quality research. Obtaining informed consent is made complicated by the fact that critically ill patients often cannot speak for themselves and by the fact that their families and caregivers are being approached for research in the midst of the emotional stress of their loved ones’ sudden illness and the burden of complex decisions about medical care. Other challenges include the difficulty identifying and controlling intervening variables, heterogeneity among patients within study populations, defining “usual care,” and generalizing results (ie, generating findings that are transferable to other institutions, rather than applicable only in the institutions where the research was conducted). In order to be successful, critical care researchers must have a sustained passion for finding new knowledge that will improve practice and a steadfastness to continue to seek solutions to the considerable obstacles that exist in conducting critical care research.

Can grit be enhanced? Although Duckworth posited grit as a stable and enduring personality trait,²  there has been considerable interest in developing interventions to improve individual grit, particularly in the context of elementary and secondary education. Several strategies have been proposed for increasing grit in health care students and providers. Seguin suggests that grit might be enhanced by identifying role models for grit, selecting specific goals to see through to completion, cultivating a growth mindset, and identifying one’s purpose in work.¹⁰  In light of Megan Brunson’s observation that, “We have to be willing to face failure and start over again with lessons learned,”¹  strategies to support clinicians in persistence and lifelong learning also might be helpful in increasing grit among members of the health care team. However, these interventions have not been empirically tested, and it is not clear whether such interventions will be effective.⁴ 

Passion is the bedrock of grit, while perseverance is what gives grit its staying power. AACN’s vision captures the essence of critical care nurses’ patient- and family-centered passion (“AACN is dedicated to creating a healthcare system driven by the needs of patients and families where acute and critical care nurses make their optimal contribution”¹¹ ). Passion is essential, because it provides the focus for persistent efforts that ultimately lead to success.

Gritty, unstoppable clinical providers will focus on applying the best evidence to patient care. Applying the best evidence depends on gritty, unstoppable researchers advancing the knowledge base for practice, and on both clinicians and researchers always questioning whether something can be done better than before. Gritty, unstoppable nurses will leverage the power of teamwork to persevere in achieving collective goals of improving patient and family outcomes.

Gritty, unstoppable clinicians never cease building their professional knowledge and skills. Gritty providers engage in lifelong learning. This spirit of engagement is always evident at AACN’s NTI, where nurses actively seek out educational sessions, new products and resources, and innovative solutions. Educational systems that provide clear and seamless articulation to higher educational degrees, as envisioned by the Institute of Medicine of the National Academies report, “The Future of Nursing: Leading Change, Advancing Health,”¹²  will further empower unstoppable nurses.

Megan Brunson has challenged critical care nurses to be unstoppable. She said,

Passion and perseverance can be keys to success for all of us.