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Resilience in nursing students: An integrative review
Nurse Education Today 36 (2016) 457–462
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Review
Resilience in nursing students: An integrative review☆ Lisa Jean Thomas a,b,1, Susan Hunter Revell c,2 a b c
Lawrence Memorial Regis College Nursing Program, 170 Governors Avenue, Medford MA 02155, United States Doctoral Student University of Massachusetts Dartmouth, United States University of Massachusetts Dartmouth, 285 Old Westport Rd, North Dartmouth, MA 02747, United States
a r t i c l e
i n f o
Article history: Accepted 15 October 2015 Keywords: Resilience Nursing students Nursing education Pre licensure Integrative review
s u m m a r y Objective: The aim of this integrative review was to investigate the state of knowledge on resilience in nursing students. Specifically the authors sought to define and describe the concept, and identify factors that affect and evaluate strategies to promote resilience in nursing students. Design: Integrative literature review. Data Sources: Cumulative Index to Nursing and Allied Health (CINHAL), Education Resources Information Center (ERIC) and PsychINFO electronic databases were searched for publications between 1990 and 2014. Search terms included resilience, student, nurse, nursing student, hardiness, emotional resilience, research, resili*, and nurse*. Review Methods: Whittemore and Knafl's integrative approach was utilized to conduct the methodological review. Each article was assessed with an appraisal tool. Results: The search resulted in the inclusion of nine articles. The majority of the literature utilized definitions of resilience from the discipline of psychology. One exception was a definition developed within nursing specific to nursing students. Factors that affect resilience were grouped into three themes: support, time, and empowerment. Strategies to promote resilience in nursing students were found in three of the nine articles, but their methods and findings were disparate. Conclusions: This review provides information about the concept of resilience in nursing students. Faculty awareness of the importance of resilience in nursing students can better prepare students for the role of the professional nurse. Support from family, friends and faculty impact a student's resilience. Through closely working with students in advisement, the clinical arena and the classroom faculty can promote resilience. © 2015 Elsevier Ltd. All rights reserved.
Introduction Resilience is defined as the ability to overcome adversity and includes how one learns to grow stronger from the experience (McAllister and McKinnon, 2009). Understanding resilience in nursing students is essential due to higher levels of academic stress when compared to students in other health majors (Edwards, Burnard, Bennett, and Hebden, 2010). In addition to academic pressure, nursing students are exposed to many firsts in the clinical arena, including death and dying, diverse lifestyles, and communicable diseases in real time (Stephens, 2013). The student's experiences are stressful as they apply new concepts and skills in a practice environment. This new role often necessitates that students reconsider personal beliefs and values (Stephens, 2013). The well-known Carnegie Foundation report recommends that nurse educators shift from socializing nursing students to emphasizing
☆ The authors of this review received no funding. E-mail addresses: [email protected] (L.J. Thomas), [email protected] (S.H. Revell). 1 Tel.: +1 781 696 9318; fax: +1 978 261 5640. 2 Tel.: +1 508 999 8507.
http://dx.doi.org/10.1016/j.nedt.2015.10.016 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
the formation of nurses (Benner, Sutphen, Leonard, and Day, 2010). Becoming a nurse is more than being socialized into the role. The protective factors identified in the concept of resilience include having optimism, a sense of humor, flexibility, and self-efficacy. It is believed that enhancing resilience through these factors, directly relates to the formation of nursing students (McAllister and McKinnon, 2009). To date, no integrative review has been done about resilience in nursing students. Thus the purpose of this integrative review was to synthesize the literature about resilience in this population. Specific aims focus on the definition of resilience and factors that contribute to resilience in nursing students. Strategies to promote resilience and outcomes from nursing research were also examined to facilitate a better understanding of the concept. Background The concept of resilience has evolved over time; its origins can be traced to the discipline of psychology with work beginning in the 1970s (Garmzey, Masten and Tellegen, 1984). Garmezy et al. (1984) studied resilience in youth whose parents suffered with schizophrenia, and found that some children fared better than others despite their environment. Researchers identified protective factors that people with
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resilience possess such as, positive outlook, self-esteem, problem solving skills, critical thinking skills and humor. Beginning in the late 1980s, researchers examined external influences of resilience. These included environmental factors such as families and characteristics of their social community (Luthar, Cicchetti and Becker, 2000). Positive external factors noted were: perceived social support, a sense of connectedness, and life events (Tusaie and Dyer, 2004). While adverse environmental factors included: exposure to violence, poverty, and parental mental health issues (Luthar et al., 2000). During the early 2000s, resilience researchers ignited a paradigm shift among scholars by moving from examining character traits and risk factors to evaluating strengths that may prevent psychological issues (Richardson, 2002). Richardson's (2002) theoretical work described resilience as a process of coping with adversity or disruptions in a way that strengthened protective factors associated with resilience. He described resilience as progressive and modifiable through education. Waite and Richardson (2004) tested the efficacy of a resiliencetraining program in the workplace. A randomized control study was conducted, the experimental group received resilience training, and the control group did not. Significant findings were found in select measurements of resilience including: self-esteem, locus of control, purpose of life and interpersonal relations (Waite and Richardson, 2004). These findings supported the hypothesis that resilience is modifiable. Nurse scholars have researched the concept of resilience within the context of chronic illness including asthma, HIV/AIDS and diabetes. Vinson (2002) tested a child resilience model in children with asthma. The constructs of resilience were found to have a significant impact on health outcomes including management of symptoms, emergency room visits and hospitalizations (Vinson, 2002). Researchers have investigated nurses as role models and sources of support to develop resilience in patients with HIV/AIDS (Dyer, Patsdaughter, McGuinness, O'Connnor, and Desantis, 2004). It was found that nurses who are resilient, assess their patients for strengths, and then partnered with patients to manage their care, had better patient health outcomes (Dyer et al., 2004). Resilience training positively impacted health outcomes in a study by Bradshaw et al. (2007). Researchers conducted a multidisciplinary interventional study in patients with type two diabetes. The experimental group received resilience education while the control group received standard treatment. Members of the intervention group had significant increases in exercise, dietary control and psychosocial measurements (Bradshaw et al., 2007). The above studies illustrate the importance of resilience in chronic illness across ages and diagnoses. Resilience research led nurse researchers to investigate the phenomenon within the discipline of nursing. Nurses are intimately involved with suffering and tragedy on a daily basis and are instrumental in helping others overcome adversity (Jackson, Firtko, and Edenborough, 2007). This adversity can in turn cause stress within the nurse, thus resilience is important to nurses in their everyday practice (Jackson et al., 2007). A correlational cross-sectional survey design study with operating room nurses found significant correlations with the measure of resilience and hope, self-efficacy, coping, control and competence (Gillspie et al., 2007). These findings support the notion that a nurse's level of resilience matters. Hodges, Keeley and Troyan (2008) conducted a qualitative study to understand the role of resilience in new graduate nurses. Adjusting to the role of the nurse poses adversity, but professional resilience was found to facilitate the new nurses self-protection, risk taking, and forward motion through reflection (Hodges et al., 2008). A literature review about personal resilience in the face of workplace adversity offered the following strategies to enhance resilience in nurses: mentoring relationships, life balance and spirituality, positive emotions and personal growth and professional reflection (Jackson et al., 2007). Based on this review an educational intervention study was conducted with nurses and midwives (McDonald, Jackson, Wilkes, and Vickers, 2013). The intervention was delivered
through workshops. Topics included: mentoring, positive outlook, hardiness, intellectual flexibility, emotional intelligence, life balance, spirituality, reflection and critical thinking (McDonald et al., 2013). Data was collected through qualitative interviews following the intervention. Several professional gains were identified including increased assertiveness, supportive communication, closer staff dynamic, and an understanding of self-care as it relates to resilience (McDonald et al., 2013). Researchers have made clear recommendations to incorporate resilience training into nursing education (Hodges et al., 2008; Jackson et al., 2007; McDonald et al., 2013). However, the approach to achieve this training is less clear. This integrative review has sought to synthesize the literature and expand the knowledge base of nurse educators about how to foster resilience in students. Aim and Questions Aim The aim of this integrative review is to examine the literature related to resilience among nursing students. For the purpose of the review, publications about pre-licensure nursing students at any educational level were considered. Questions 1 How is resilience among nursing students defined or described? 2 What factors affect or contribute to resilience in nursing students? 3 In what ways has resilience been promoted among nursing students? Method An integrative review was conducted, using the framework by Whittemore and Knafl (2005) and Cooper (1998), to explore the literature on resilience among nursing students. The method was chosen because it integrates theoretical literature, qualitative research and quantitative studies (Whittemore and Knafl, 2005). This approach allows for a variety of perspectives and in turn enables the reviewer to better understand the concept. Whittemore and Knafl's (2005) integrative review method consists of five stages: problem identification, literature search, data evaluation, data analysis and presentation. Search Strategy The search was conducted between September and November of 2014 using the computerized databases of: Cumulative Index to Nursing and Allied Health (CINHAL), Education Resources Information Center (ERIC) and PsychINFO. Published literature was searched between 1990 and 2014. This time frame was chosen because Wagnild and Young (1993) first measured resilience in nursing in the late 1980s. Psychometric testing began in 1993 (Wagnild and Young, 1993). Search terms included resilience, student, nurse, nursing student, hardiness, emotional resilience, research, resili*, and nurse* (see Table 1 for details). Ancestry searches of retrieved articles were done to enhance Table 1 Search terms. Concept
Subject headings
Text words
Resilience
Resilience, nursing student, emotional resilience
Hardiness
Hardiness, nursing student
Resilience, resilie* Emotional resilience Nurse*, nursing student, nurse and student Hardiness Nurse*, nursing student, nurse and student
Years of publication 1990–2014.
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the search strategy. Articles were included or excluded based on the questions posed for this review. Screening From the search described above 93 articles were identified (see Fig. 1 for data search process). A screening process eliminated duplicates, which resulted in 45 articles. The abstracts of these articles were evaluated based on the following inclusion criteria: (a) described resilience in nursing students, (b) measured resilience in pre-licensure nursing students, (c) published between 1990 and 2014, (d) grey literature was included and (e) published in English. International research was included if it met the inclusion criteria. Publications were excluded if the focus was on nurses in the workplace post-licensure. Several studies discussed teaching students to use resilience techniques in the patients they care for thus they did not meet the eligibility criteria. One doctoral dissertation was not used due to availability. From the 45 abstracts 18 full text articles were assessed for eligibility. From these, nine articles met the criteria for the integrative review. Analysis The final literature selected for the review included both theoretical and empirical work (see Table 2). The literature included a variety of methods, descriptive, correlational, ethnography, case study and phenomenological. Evaluation is more complex when there is greater diversity in methodology (Whittmore and Knafl, 2005). A critical appraisal tool and protocol developed by Hawker, Payne, Kerr, Hardey and Powell (2002) was used to evaluate each article. This protocol defines each criterion in detail and scores each piece as good, fair, poor and very poor. For this review, articles that scored good and fair were assigned a 1 and articles that scored poor and very poor were assigned a 2. The high and low score is based on the relevance to the topic, and the rigor of the method employed (Sullivan and Asselin, 2013). Analysis of the nine articles was guided by the three questions. Each article was thoroughly read, then scored based on the classification noted. The analysis was done in three phases. In the first phase, a
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process to analyze and classify points associated with each of the three questions was completed. Individual analysis was executed for each article, and then comparisons were made between the articles to evaluate trends in the literature. Data was organized into a data matrix to facilitate the categorization process (Sullivan and Asselin, 2013). Articles that scored a two on relevance and rigor were then reviewed. In the second phase, articles that scored a one on relevance and rigor were reviewed. Similar to phase one, the articles were assessed in relation to each of the three questions. The findings of the level one articles were then compared to the level two articles. In the last phase integration and summation of the significant findings related to each question were completed. Key points were themed and presented (Sullivan and Asselin, 2013). Results Definition and Description of Resilience in Nursing Students Resilience in nursing students is not well defined in the literature. Definitions are broad and originate from the discipline of psychology. The authors of seven articles clearly define resilience while three researchers did not offer a specific definition (see Table 3). When comparing definitions across studies, authors describe resilience in relation to a stressor or adversity, offer a set of personal characteristics, and identify a coping outcome. The term adversity is used in many of the definitions (Pines et al., 2014; Stephens, 2013; Taylor and Reyes, 2012), whereas suffering and emerging difficulties is unique to Hodges, Keeley and Grier (2005). Carroll (2011) and Stephens (2013) use the term stress, which is an interesting point because both of these researchers have a greater focus on nursing academics. In 2012, Stephens used Ahern's definition of resilience in adolescents, which includes risk as its antecedent. Character traits described by researchers in the discipline of psychology persist in definitions used in current nursing literature. Attributes such as internal qualities (Caroll, 2011), human traits (Pines et al., 2012) and personal characteristics (Stephens, 2012; Stephens, 2013) are used to define resilience. Two sources include external factors in their definitions; family and social support and community resources (Caroll, 2011; Taylor and Reyes, 2012). The simple but powerful statement “resilience is the ability to bounce back” is a consequence identified by Pines et al. (2012). Three researchers use adaptation as a way to describe the ability to overcome adversity (Stephens, 2012; Stephens, 2013; Taylor and Reyes, 2012). The consequence of perseverance and the integration of the experience into oneself was used in one study (Hodges, Keeley and Grier, 2005). Carroll (2011) is the only researcher that specifies academic success as an outcome of resilience. Stephens (2013) conducted a concept analysis of nursing student resilience. She utilized the Norris method that requires the development of an operational definition of the concept. Based on the literature reviewed she proposed the following: “nursing student resilience is an individualized process of development that occurs through the use of personal protective factors to successfully navigate perceived stress and adversities. Cumulative successes lead to enhanced coping/adaptive abilities and well-being” (p.130). This is the only definition that specifically addresses resilience in nursing students. Factors Affecting Resilience in Nursing Students
Fig. 1. Data collection process.
Support was identified as an important factor of resilience in nursing students. Family, friends and faculty support were discussed in two studies (Carroll, 2011; Crombie, Brindley, Harris, Marks-Maran and Thompson, 2013). These studies focused on retention and entry into the profession, with researchers reporting difficulty with retention of students and nursing shortages. Carroll (2011) conducted a phenomenological study with associate degree students to investigate the lived experience of resiliency and the completion of the program. She interviewed final semester students who were doing well academically
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Table 2 Matrix of literature reviewed. Author year/country
Methodology
Setting/sample
Strategies/findings
Quality 1 = high 2 = low
Pines et al. (2014) US
Pilot interventional study
Descriptive longitudinal
Crombie et al. (2013) UK
Ethnographic case study
• Four training modules over two semesters. • The only measure within the SRP that had a significant result was that of necessitating • Otherwise no significant findings • No change in resilience score with the three year gap • Older students were found to have higher levels of resilience • Fostering resilience • Peer group support in clinical and class • Family as support structure
1
Pitt et al. (2014) AU
60 undergrad upper division nursing students Small faith based college South West US 138 entry level with repeated measures three years later at the end of the program
Stephens (2013) US
Concept clarification (Norris method)
1
Stephens (2012) US
Interventional repeated measures during a twitter intervention Pretest posttest quasi-experimental design
• • • •
Taylor et al. (2012) US
28 second year adult nursing students 2 clinical sites London and west of London Clarify the concept of resilience in nursing students 70 junior level students 2 state supported Universities 136 matched pairs undergrad, all levels but freshman Location not specified
•
• • Pines et al. (2012) US
Correlational
Carroll (2011) US
Phenomenological
166 generic BSN Jr and Sr level. South West US 11 undergrad students near graduation California
Hodges et al. (2005)
Theoretical
Focus on Parse's HBST
and scored high on a Sense of Coherence (SOC) tool. The SOC was used as a screening tool. It was found that family support was the most common occurring theme. An ethnographic case study conducted with students in their second year of a London based university found that resilience influenced rates of program completion (Crombie et al., 2013). Furthermore Carroll (2011) and Crombie et al. (2013) found that encouragement from parents, significant others, children, grandparents and in-laws fostered resilience in students. Of these, mothers were mentioned most often (Carroll, 2011). Friendships were also identified as important to resilience, especially integration into a supportive peer group within the nursing program (Carroll, 2011; Crombie et al., 2013). Lifelong friendships also contribute to resilience according to Carroll (2011). Examples of faculty support were illustrated in the interviews and determined to be valuable to student resilience (Carroll, 2011). These two qualitative studies found that family, peer, and faculty support impact resilience in students. To date, quantitative work has not been done to correlate resilience with these factors. Varying results have been found regarding the impact of time on resilience in students. In a descriptive study in England, researchers explored nursing student personal qualities of resilience in first semester freshman students and then again prior to graduation three years later (Pitt, Powis, Levett-Jones and Hunter, 2014). The results showed no statistical difference in resilience scores over time, but researchers noted that older students scored higher on resilience instruments than their younger counterparts (Pitt et al., 2014). In contrast, Taylor and Reyes (2012) measured resilience in relation to test scores. They found that two measures on the Wagnild and Young Resilience Scale had statistical significance between the beginning and end of a semester. The measurement of perseverance, and existential aloneness both increased over this time period (Taylor and Reyes, 2012). The increase in perseverance may be attributed to a student's sense of determination, while the existential aloneness may be related
• •
• • •
Operational definition Nursing student model Hypothesis Experimental group had increased resilience post but not at follow up Two subsets of the RS perseverance and existential aloneness had sig increases from beginning of semester to end, No difference in RS across the curriculum Significant moderate correlation of RS between grades on the 1st and last exam Resilience and empowerment were positively correlated Themes found: support, perseverance, autonomy, empathy, high expectations, sense of purpose, optimism, honesty, critical thinking Coaching role for faculty Reflection, connection, resilience Professional identity related to resilience
1
2
1 2
1 1
1
to their ability to reach within themselves to succeed (Taylor and Reyes, 2012). In contrast Stephens (2012) believed that cumulative success led to increased resilience. It is difficult to compare these studies because different instruments and methods were used, but overall the literature supports that the passage of time makes a difference in a student's measured level of resilience. There is a positive correlation between empowerment and resilience (Pines et al., 2012). This factor was only reported in one study. The researchers measured resilience in relation to empowerment and conflict management styles and found that students with high measures of empowerment had high levels of resilience. This may be beneficial in preparing students for handling conflicts in the workplace. Strategies to Promote Resilience in Nursing Students Three studies in this review approached the promotion of resilience in nursing students. Two are interventional studies (Pines et al., 2014; Stephens, 2012) and one is a theoretical paper that offers recommendations based on Parse's theory (Hodges et al., 2005). Strategies posited in these papers include reflection (Hodges et al., 2005), simulation and debriefing (Pines et al., 2014), and resilience messages delivered through twitter (Stephens, 2012). Each of these will be discussed separately because their methods and findings are diverse. It has been proposed that Parse's theory can be a framework for undergraduate education that can enhance professional identity and resilient nurses. A theoretical paper by Hodges et al. (2005) posits that nurse educators can develop resilience in students by teaching students to reflect and persevere in the face of conflict. Faculty can work with students to identify success and build upon them. They can assist students that are having a difficult day to refocus and view it as a challenge and as an opportunity to overcome barriers. By acknowledging professional stamina, students can be taught the value of determination. Reflection, connection and resilience were presented as a whole. Hodges et al.
L.J. Thomas, S.H. Revell / Nurse Education Today 36 (2016) 457–462 Table 3 Definitions and descriptions of resilience across the literature. Author
Definition/description
“Resilience consists of suffering and perseverance, working through emerging difficulties and integrating crisis experiences into one's sense of well being” (p. 550) Pines, Rauschhuber, Cook, Norgan, “Resilience is the ability of an individual to adjust to adversity, maintain equilibrium, Canchola, Rischardson and retain some control over the environment and Jones (2014) move in a positive direction.” (p. 86) Pines et al. (2012) “Resilience is the ability to bounce back. The personal attributes of resilient people include an internal locus of control, pro-social behavior, empathy, positive self image, optimism and the ability to organize daily responsibilities.” (p. 1483) Carroll (2011) “Resiliency refers to the construct that the nursing student way be equipped with internal qualities and/or be supported by external forces that promote academic success in spite of stressful circumstances. (p. 13) Stephens (2012) Ahern's definition of adolescent resilience is used for theoretical and conceptual congruence. Adolescent resilience as a “process of adaptation to risk that incorporates personal characteristics, family and social support, and community resources” (p. 3). Stephens (2013) “Nursing student resilience is an individualized process of development that occurs through the use of personal protective factors to successfully navigate perceived stress and adversities. Cumulative success lead to enhanced coping/adaptive abilities and well-being.” (p. 130) Taylor and Reyes (2012) “Resilience in individuals has been defined as the ability to rise above difficult situations; adapt better than expected in the face of significant adversity; and recover from difficulty and overcome adverse circumstances in one's life”. (p. 2) Hodges, Keeley and Grier (2005)
(2005) propose that reflection should be developed early in conjunction with other basic nursing skills. “Resilience can develop from intentional reflection, step by cumulative step” (Hodges et al., 2005, p.553). The act of writing allows a student a time away from the noise and busyness of practice to think and construct thoughts about nursing. Through the reflection, instructors have a window into what a student is experiencing and can navigate and support the student to build resilience (Hodges et al., 2005). A pilot study was conducted to evaluate the use of a resilience intervention with nursing students based on the “Reaching Out and Reaching In” curriculum. (Pines et al., 2014). This program has been successful in young children, adolescents and college students (Pines et al., 2014). The curriculum was adapted specifically for nursing students and topics included: principles of resiliency and behaviors of resilient nurses, professional empowerment strategies in the workplace, conflict management styles and teamwork training. Four modules were presented over two semesters consisting of class followed by simulation and debriefing. The purpose of the pilot was to evaluate whether nursing students who participated in resilience education would have increased resiliency scores at the end of the program. Resilience was measured with the Stress Resiliency Profile (SRP), empowerment and conflict management were also measured. There were no significant changes in resilience scores from pretest to posttest (Pines et al., 2014). This demonstrates the complexity required to enhance resilience in nursing students. Stephens (2012) conducted a study using twitter to deliver an educational intervention to enhance resilience in nursing students. This multisite study consisted of an experimental and control group, with resilience measured by The Connor-Davidson Resilience Scale using a
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pretest, posttest and follow-up design. The participants were junior level baccalaureate student's aged 19–23. Students in the experimental group received four educational messages or questions (tweets) each week that were intended to promote resilience. Students in the control group got four tweets with nursing trivia or basic nursing information. Like the Pines et al. study the intervention was “loosely” based on the “Reaching Out and Reaching In” curriculum. A different theme was highlighted each week. The themes included: social support, positive emotions, humor, knowledge of health behaviors, self-knowledge and effective coping. Questions included: What is your greatest strength? How does this help you? Who is the most positive influence in your life? What can you learn from him/her? If a student tweeted, other students could respond and have dialog but the researcher did not. Resilience scores initially increased between pretest and posttest, but then declined at follow up (Stephens, 2012). The pilot study done by Pines et al. (2014) does not provide detailed information regarding the educational sessions that were administered to students. This makes the comparison to the Stephens' (2013) study difficult. Stephens' (2013) research is a dissertation therefore great detail about the intervention was provided. The theoretical information developed by Hodges et al. (2005) is very interesting but has not been tested. This variation is a limitation to the integration of strategies to enhance resilience in nursing students. More work in both theoretical and interventional specific to nursing students needs to be done in the area of resilience.
Discussion The concept of resilience in nursing students is in its infancy. With the exception of one theoretical article that was written in 2005, the remaining work has been published within the last three years. Stephens (2013) constructed a definition and model through her concept analysis but thus far it has not been utilized or tested. It was hoped that through this review more description of resilience in nursing students would be evident, however that is not yet clear in the literature. This is a limitation. A well-tested definition would allow for clarity in the measurement of resilience. The use of a consistent definition can aid in the comparison of studies thus making the science stronger. This is a critical point in the literature that has not been well established. It would be beneficial to further examine factors that contribute to resilience in nursing students through qualitative research. Data gathered would either support Stephens' (2013) definition or further refine it. There are multiple studies that correlate resilience in relation to other variables, academic success, self-efficacy and empowerment but no studies provide an answer to the question; what variables impact resilience in nursing students? A quantitative descriptive study to answer this question would further define the concept of resilience as it relates to nursing students. Research has identified resilience as important for nurses which led to the notion of enhancing resilience in nursing students to better prepare them for their professional role (Hodges, Troyan and Keeley, 2010; Jackson et al., 2007; McAllister and McKinnon, 2009; Pines et al., 2012; Stephens, 2013). The two interventional studies reviewed utilized social media (Stephens, 2012) and classroom educational modules (Pines et al., 2014). Stephens' (2012) Twitter intervention initially demonstrated an increase in resilience at posttest, however when evaluated again one-month post the resilience scores had decreased. Pines et al. (2014) set of four modules over two semesters did not result in an increase in resilience measures. It could be said that the frequent short interventions in Stephens' (2012) study are more beneficial than more sporadic interventions over two semesters in the Pines' et al. (2014) study. A direction for further research may include short doses of interventions over a longer period of time to assess effectiveness. The time of delivery during a nursing program is also a consideration. Research that evaluates the effectiveness of enhancing resilience at various points of
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education would be valuable. Is an intervention more effective early or late in a nursing program? Reflection in relation to resilience is an interesting idea however formal research to investigate its connection is lacking. Davies (1995) conducted a grounded theory study over twenty years ago that demonstrated reflection as a strategy to reduce anxiety in students and facilitate active learning skills. Since that time reflection has been utilized in various ways within nursing education. From the theoretical work that Hodges et al. (2005) conducted paired with the effectiveness of this tool (Davies, 1995) it is reasonable to hypothesize that reflection can facilitate resilience in students. Hodges et al. (2005) recommend beginning reflection early in their education as students are learning other nursing skills. Reflection continues to be valuable for students after graduation. There is research evidence to support that reflection aids new graduates to assimilate the discrepancies between their perceived role and the reality of being a professional nurse. The outcome of this process is termed emotional labor (Hodges et al., 2008). Research exploring reflection in relation to a student's resilience and new graduate's resilience would expand knowledge in this area. Despite resilience in nursing students being a relatively new research topic, there is sufficient information in the literature to inform faculty how to promote resilience. Nurse educators are in a unique position to facilitate the development of resilience in the students they teach (Stephens, 2013). Student resilience is important to consider regardless of the role of the faculty. Faculty can coach students to draw upon their resources to overcome challenges faced (Hodges et al., 2005). The support of family, friends and faculty has been shown to impact student resilience and encouraging students to access these resources may be beneficial. Promoting students to think about previous times they overcame obstacles may help stimulate them to persevere and reach higher to overcome the struggles they are currently experiencing (Stephens, 2013). Instructors can help students reframe experiences, from viewing it negatively to seeing it as a learning experience (Hodges et al., 2005). By asking the questions, what did you learn? Has this experience made you more knowledgeable or stronger? (Stephens, 2013), nursing faculty can promote more resilient nurses. Nurse faculty are responsible to prepare students to be professional nurses in a healthcare environment that has been described as fast paced, chaotic and full of conflict (McAllister and McKinnon, 2009; Pines et al., 2014). Resilience plays a role in that preparation, because this concept has been identified as an essential element for nursing practice. According to Grafton, Gillespie and Henderson (2010) resilience positively impacts nurse satisfaction, retention and can enhance patient care. Therefore, nurse educators are challenged to incorporate resilience education into nursing curriculum (Hodges et al., 2005). As illustrated in this paper, resilience in nursing students needs to be expanded and incorporated into education. The importance of resilience has been demonstrated, but a stronger knowledge of what affects a student's level of resilience and how resilience can be enhanced is needed. In order to develop this further a clear definition of the concept in nursing students needs to be tested, and then used consistently. From this theoretical models can be developed and evaluated. Conclusion This integrative review provides information to nursing faculty about the concept of resilience in nursing students. Resilience can affect a student's perseverance, academic success and empowerment. Faculty guidance of the student into the role of professional nurse is crucial. Thus it is important to foster resilience in nursing students to prepare them for longevity in today's healthcare system.
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Grafton, E., Gillespie, B., Henderson, S., 2010. Resilience: the power within. Oncol. Nurs. Forum 37 (6), 698–705. http://dx.doi.org/10.1188/10.ONF.698-705. Hawker, S., Payne, S., Kerr, C., Hardey, M., Powell, J., 2002. Appraising the evidence: reviewing disparate data systematically. Qual. Health Res. 12 (9), 1284. Hodges, H.F., Keeley, A.C., Grier, E.C., 2005. Professional resilience, practice longevity, and parse's theory for baccalaureate education. J. Nurs. Educ. 44 (12), 548. Hodges, H., Keeley, A., Troyan, P., 2008. Professional resilience in baccalaureate-prepared acute care nurses: first steps. Nurs. Educ. Perspect. 29 (2), 80–89. Hodges, H.F., Troyan, P.J., Keeley, A.C., 2010. Career persistence in baccalaureate-prepared acute care nurses. J. Nurs. Scholarsh. 42 (1), 83–91. http://dx.doi.org/10.1111/j.15475069.2009.01325.x. Jackson, D., Firtko, A., Edenborough, M., 2007. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. J. Adv. Nurs. 60 (1), 1–9. http://dx.doi.org/10.1111/j.1365-2648.2007.04412.x. Luthar, S.S., Cicchetti, D., 2000. The construct of resilience: implications for interventions and social policies. Dev. Psychopathol. 12 (4), 857–885. http://dx.doi.org/10.1017/ S0954579400004156. McAllister, M., McKinnon, J., 2009. The importance of teaching and learning resilience in the health disciplines: a critical review of the literature. Nurse Educ. Today 29 (4), 371–379. http://dx.doi.org/10.1016/j.nedt.2008.10.011. McDonald, G., Jackson, D., Wilkes, L., Vickers, M.H., 2013. Personal resilience in nurses and midwives: effects of a work-based educational intervention. Contemp. Nurse 45 (1), 134. Pines, E., Rauschhuber, M., Norgan, G., Cook, J., Canchola, L., Richardson, C., Jones, M., 2012. Stress resiliency, psychological empowerment and conflict management styles among baccalaureate nursing students. J. Adv. Nurs. 68 (7), 1482–1493. http://dx. doi.org/10.1111/j.1365-2648.2011.05875.x. Pines, W.E., Rauschhuber, L.M., Cook, D.J., Norgan, H.G., Canchola, E. Leticia, Richardson, E. Cynthia, Jones, E. Mary, 2014. Enhancing resilience, empowerment, and conflict management among baccalaureate students: outcomes of a pilot study. Nurse Educ. 39 (2), 85–90. http://dx.doi.org/10.1097/NNE.0000000000000023. Pitt, V., Powis, D., Levett-Jones, T., Hunter, S., 2014. Nursing students' personal qualities: a descriptive study. Nurse Educ. Today 34 (9), 1196–1200. http://dx.doi.org/10.1016/j. nedt.2014.05.004. Richardson, G.E., 2002. The metatheory of resilience and resiliency. J. Clin. Psychol. 58 (3), 307–321. http://dx.doi.org/10.1002/jclp.10020. Stephens, T., 2012. Increasing Resilience in Adolescent Nursing Students (Unpublished Doctoral Dissertation). The University of Tennessee, Knoxville. Stephens, T., 2013. Nursing student resilience: a concept clarification. Nurs. Forum 48 (2), 125–133. http://dx.doi.org/10.1111/nuf.12015. Sullivan, L.J., Asselin, M.E., 2013. Revisiting quality of life for elders in long-term care: an integrative review. Nurs. Forum 48 (3), 191. Taylor, H., Reyes, H., 2012. Self-efficacy and resilience in baccalaureate nursing students. Int. J. Nurs. Educ. Scholarsh. 9 (1), 1–13. http://dx.doi.org/10.1515/1548-923X.2218. Tusaie, K., Dyer, J., 2004. Resilience: a historical review of the construct. Holist. Nurs. Pract. 18 (1), 3–10. Vinson, J.A., 2002. Practice applications of research. Children with asthma: initial development of the child resilience model. Pediatr. Nurs. 28 (2), 149–158. Wagnild, G., Young, H., 1993. Development and psychometric evaluation of the resilience scale. J. Nurs. Meas. 1 (2), 165–178. Waite, P.J., Richardson, G.E., 2004. 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Review
Resilience in nursing students: An integrative review☆ Lisa Jean Thomas a,b,1, Susan Hunter Revell c,2 a b c
Lawrence Memorial Regis College Nursing Program, 170 Governors Avenue, Medford MA 02155, United States Doctoral Student University of Massachusetts Dartmouth, United States University of Massachusetts Dartmouth, 285 Old Westport Rd, North Dartmouth, MA 02747, United States
a r t i c l e
i n f o
Article history: Accepted 15 October 2015 Keywords: Resilience Nursing students Nursing education Pre licensure Integrative review
s u m m a r y Objective: The aim of this integrative review was to investigate the state of knowledge on resilience in nursing students. Specifically the authors sought to define and describe the concept, and identify factors that affect and evaluate strategies to promote resilience in nursing students. Design: Integrative literature review. Data Sources: Cumulative Index to Nursing and Allied Health (CINHAL), Education Resources Information Center (ERIC) and PsychINFO electronic databases were searched for publications between 1990 and 2014. Search terms included resilience, student, nurse, nursing student, hardiness, emotional resilience, research, resili*, and nurse*. Review Methods: Whittemore and Knafl's integrative approach was utilized to conduct the methodological review. Each article was assessed with an appraisal tool. Results: The search resulted in the inclusion of nine articles. The majority of the literature utilized definitions of resilience from the discipline of psychology. One exception was a definition developed within nursing specific to nursing students. Factors that affect resilience were grouped into three themes: support, time, and empowerment. Strategies to promote resilience in nursing students were found in three of the nine articles, but their methods and findings were disparate. Conclusions: This review provides information about the concept of resilience in nursing students. Faculty awareness of the importance of resilience in nursing students can better prepare students for the role of the professional nurse. Support from family, friends and faculty impact a student's resilience. Through closely working with students in advisement, the clinical arena and the classroom faculty can promote resilience. © 2015 Elsevier Ltd. All rights reserved.
Introduction Resilience is defined as the ability to overcome adversity and includes how one learns to grow stronger from the experience (McAllister and McKinnon, 2009). Understanding resilience in nursing students is essential due to higher levels of academic stress when compared to students in other health majors (Edwards, Burnard, Bennett, and Hebden, 2010). In addition to academic pressure, nursing students are exposed to many firsts in the clinical arena, including death and dying, diverse lifestyles, and communicable diseases in real time (Stephens, 2013). The student's experiences are stressful as they apply new concepts and skills in a practice environment. This new role often necessitates that students reconsider personal beliefs and values (Stephens, 2013). The well-known Carnegie Foundation report recommends that nurse educators shift from socializing nursing students to emphasizing
☆ The authors of this review received no funding. E-mail addresses: [email protected] (L.J. Thomas), [email protected] (S.H. Revell). 1 Tel.: +1 781 696 9318; fax: +1 978 261 5640. 2 Tel.: +1 508 999 8507.
http://dx.doi.org/10.1016/j.nedt.2015.10.016 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
the formation of nurses (Benner, Sutphen, Leonard, and Day, 2010). Becoming a nurse is more than being socialized into the role. The protective factors identified in the concept of resilience include having optimism, a sense of humor, flexibility, and self-efficacy. It is believed that enhancing resilience through these factors, directly relates to the formation of nursing students (McAllister and McKinnon, 2009). To date, no integrative review has been done about resilience in nursing students. Thus the purpose of this integrative review was to synthesize the literature about resilience in this population. Specific aims focus on the definition of resilience and factors that contribute to resilience in nursing students. Strategies to promote resilience and outcomes from nursing research were also examined to facilitate a better understanding of the concept. Background The concept of resilience has evolved over time; its origins can be traced to the discipline of psychology with work beginning in the 1970s (Garmzey, Masten and Tellegen, 1984). Garmezy et al. (1984) studied resilience in youth whose parents suffered with schizophrenia, and found that some children fared better than others despite their environment. Researchers identified protective factors that people with
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resilience possess such as, positive outlook, self-esteem, problem solving skills, critical thinking skills and humor. Beginning in the late 1980s, researchers examined external influences of resilience. These included environmental factors such as families and characteristics of their social community (Luthar, Cicchetti and Becker, 2000). Positive external factors noted were: perceived social support, a sense of connectedness, and life events (Tusaie and Dyer, 2004). While adverse environmental factors included: exposure to violence, poverty, and parental mental health issues (Luthar et al., 2000). During the early 2000s, resilience researchers ignited a paradigm shift among scholars by moving from examining character traits and risk factors to evaluating strengths that may prevent psychological issues (Richardson, 2002). Richardson's (2002) theoretical work described resilience as a process of coping with adversity or disruptions in a way that strengthened protective factors associated with resilience. He described resilience as progressive and modifiable through education. Waite and Richardson (2004) tested the efficacy of a resiliencetraining program in the workplace. A randomized control study was conducted, the experimental group received resilience training, and the control group did not. Significant findings were found in select measurements of resilience including: self-esteem, locus of control, purpose of life and interpersonal relations (Waite and Richardson, 2004). These findings supported the hypothesis that resilience is modifiable. Nurse scholars have researched the concept of resilience within the context of chronic illness including asthma, HIV/AIDS and diabetes. Vinson (2002) tested a child resilience model in children with asthma. The constructs of resilience were found to have a significant impact on health outcomes including management of symptoms, emergency room visits and hospitalizations (Vinson, 2002). Researchers have investigated nurses as role models and sources of support to develop resilience in patients with HIV/AIDS (Dyer, Patsdaughter, McGuinness, O'Connnor, and Desantis, 2004). It was found that nurses who are resilient, assess their patients for strengths, and then partnered with patients to manage their care, had better patient health outcomes (Dyer et al., 2004). Resilience training positively impacted health outcomes in a study by Bradshaw et al. (2007). Researchers conducted a multidisciplinary interventional study in patients with type two diabetes. The experimental group received resilience education while the control group received standard treatment. Members of the intervention group had significant increases in exercise, dietary control and psychosocial measurements (Bradshaw et al., 2007). The above studies illustrate the importance of resilience in chronic illness across ages and diagnoses. Resilience research led nurse researchers to investigate the phenomenon within the discipline of nursing. Nurses are intimately involved with suffering and tragedy on a daily basis and are instrumental in helping others overcome adversity (Jackson, Firtko, and Edenborough, 2007). This adversity can in turn cause stress within the nurse, thus resilience is important to nurses in their everyday practice (Jackson et al., 2007). A correlational cross-sectional survey design study with operating room nurses found significant correlations with the measure of resilience and hope, self-efficacy, coping, control and competence (Gillspie et al., 2007). These findings support the notion that a nurse's level of resilience matters. Hodges, Keeley and Troyan (2008) conducted a qualitative study to understand the role of resilience in new graduate nurses. Adjusting to the role of the nurse poses adversity, but professional resilience was found to facilitate the new nurses self-protection, risk taking, and forward motion through reflection (Hodges et al., 2008). A literature review about personal resilience in the face of workplace adversity offered the following strategies to enhance resilience in nurses: mentoring relationships, life balance and spirituality, positive emotions and personal growth and professional reflection (Jackson et al., 2007). Based on this review an educational intervention study was conducted with nurses and midwives (McDonald, Jackson, Wilkes, and Vickers, 2013). The intervention was delivered
through workshops. Topics included: mentoring, positive outlook, hardiness, intellectual flexibility, emotional intelligence, life balance, spirituality, reflection and critical thinking (McDonald et al., 2013). Data was collected through qualitative interviews following the intervention. Several professional gains were identified including increased assertiveness, supportive communication, closer staff dynamic, and an understanding of self-care as it relates to resilience (McDonald et al., 2013). Researchers have made clear recommendations to incorporate resilience training into nursing education (Hodges et al., 2008; Jackson et al., 2007; McDonald et al., 2013). However, the approach to achieve this training is less clear. This integrative review has sought to synthesize the literature and expand the knowledge base of nurse educators about how to foster resilience in students. Aim and Questions Aim The aim of this integrative review is to examine the literature related to resilience among nursing students. For the purpose of the review, publications about pre-licensure nursing students at any educational level were considered. Questions 1 How is resilience among nursing students defined or described? 2 What factors affect or contribute to resilience in nursing students? 3 In what ways has resilience been promoted among nursing students? Method An integrative review was conducted, using the framework by Whittemore and Knafl (2005) and Cooper (1998), to explore the literature on resilience among nursing students. The method was chosen because it integrates theoretical literature, qualitative research and quantitative studies (Whittemore and Knafl, 2005). This approach allows for a variety of perspectives and in turn enables the reviewer to better understand the concept. Whittemore and Knafl's (2005) integrative review method consists of five stages: problem identification, literature search, data evaluation, data analysis and presentation. Search Strategy The search was conducted between September and November of 2014 using the computerized databases of: Cumulative Index to Nursing and Allied Health (CINHAL), Education Resources Information Center (ERIC) and PsychINFO. Published literature was searched between 1990 and 2014. This time frame was chosen because Wagnild and Young (1993) first measured resilience in nursing in the late 1980s. Psychometric testing began in 1993 (Wagnild and Young, 1993). Search terms included resilience, student, nurse, nursing student, hardiness, emotional resilience, research, resili*, and nurse* (see Table 1 for details). Ancestry searches of retrieved articles were done to enhance Table 1 Search terms. Concept
Subject headings
Text words
Resilience
Resilience, nursing student, emotional resilience
Hardiness
Hardiness, nursing student
Resilience, resilie* Emotional resilience Nurse*, nursing student, nurse and student Hardiness Nurse*, nursing student, nurse and student
Years of publication 1990–2014.
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the search strategy. Articles were included or excluded based on the questions posed for this review. Screening From the search described above 93 articles were identified (see Fig. 1 for data search process). A screening process eliminated duplicates, which resulted in 45 articles. The abstracts of these articles were evaluated based on the following inclusion criteria: (a) described resilience in nursing students, (b) measured resilience in pre-licensure nursing students, (c) published between 1990 and 2014, (d) grey literature was included and (e) published in English. International research was included if it met the inclusion criteria. Publications were excluded if the focus was on nurses in the workplace post-licensure. Several studies discussed teaching students to use resilience techniques in the patients they care for thus they did not meet the eligibility criteria. One doctoral dissertation was not used due to availability. From the 45 abstracts 18 full text articles were assessed for eligibility. From these, nine articles met the criteria for the integrative review. Analysis The final literature selected for the review included both theoretical and empirical work (see Table 2). The literature included a variety of methods, descriptive, correlational, ethnography, case study and phenomenological. Evaluation is more complex when there is greater diversity in methodology (Whittmore and Knafl, 2005). A critical appraisal tool and protocol developed by Hawker, Payne, Kerr, Hardey and Powell (2002) was used to evaluate each article. This protocol defines each criterion in detail and scores each piece as good, fair, poor and very poor. For this review, articles that scored good and fair were assigned a 1 and articles that scored poor and very poor were assigned a 2. The high and low score is based on the relevance to the topic, and the rigor of the method employed (Sullivan and Asselin, 2013). Analysis of the nine articles was guided by the three questions. Each article was thoroughly read, then scored based on the classification noted. The analysis was done in three phases. In the first phase, a
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process to analyze and classify points associated with each of the three questions was completed. Individual analysis was executed for each article, and then comparisons were made between the articles to evaluate trends in the literature. Data was organized into a data matrix to facilitate the categorization process (Sullivan and Asselin, 2013). Articles that scored a two on relevance and rigor were then reviewed. In the second phase, articles that scored a one on relevance and rigor were reviewed. Similar to phase one, the articles were assessed in relation to each of the three questions. The findings of the level one articles were then compared to the level two articles. In the last phase integration and summation of the significant findings related to each question were completed. Key points were themed and presented (Sullivan and Asselin, 2013). Results Definition and Description of Resilience in Nursing Students Resilience in nursing students is not well defined in the literature. Definitions are broad and originate from the discipline of psychology. The authors of seven articles clearly define resilience while three researchers did not offer a specific definition (see Table 3). When comparing definitions across studies, authors describe resilience in relation to a stressor or adversity, offer a set of personal characteristics, and identify a coping outcome. The term adversity is used in many of the definitions (Pines et al., 2014; Stephens, 2013; Taylor and Reyes, 2012), whereas suffering and emerging difficulties is unique to Hodges, Keeley and Grier (2005). Carroll (2011) and Stephens (2013) use the term stress, which is an interesting point because both of these researchers have a greater focus on nursing academics. In 2012, Stephens used Ahern's definition of resilience in adolescents, which includes risk as its antecedent. Character traits described by researchers in the discipline of psychology persist in definitions used in current nursing literature. Attributes such as internal qualities (Caroll, 2011), human traits (Pines et al., 2012) and personal characteristics (Stephens, 2012; Stephens, 2013) are used to define resilience. Two sources include external factors in their definitions; family and social support and community resources (Caroll, 2011; Taylor and Reyes, 2012). The simple but powerful statement “resilience is the ability to bounce back” is a consequence identified by Pines et al. (2012). Three researchers use adaptation as a way to describe the ability to overcome adversity (Stephens, 2012; Stephens, 2013; Taylor and Reyes, 2012). The consequence of perseverance and the integration of the experience into oneself was used in one study (Hodges, Keeley and Grier, 2005). Carroll (2011) is the only researcher that specifies academic success as an outcome of resilience. Stephens (2013) conducted a concept analysis of nursing student resilience. She utilized the Norris method that requires the development of an operational definition of the concept. Based on the literature reviewed she proposed the following: “nursing student resilience is an individualized process of development that occurs through the use of personal protective factors to successfully navigate perceived stress and adversities. Cumulative successes lead to enhanced coping/adaptive abilities and well-being” (p.130). This is the only definition that specifically addresses resilience in nursing students. Factors Affecting Resilience in Nursing Students
Fig. 1. Data collection process.
Support was identified as an important factor of resilience in nursing students. Family, friends and faculty support were discussed in two studies (Carroll, 2011; Crombie, Brindley, Harris, Marks-Maran and Thompson, 2013). These studies focused on retention and entry into the profession, with researchers reporting difficulty with retention of students and nursing shortages. Carroll (2011) conducted a phenomenological study with associate degree students to investigate the lived experience of resiliency and the completion of the program. She interviewed final semester students who were doing well academically
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Table 2 Matrix of literature reviewed. Author year/country
Methodology
Setting/sample
Strategies/findings
Quality 1 = high 2 = low
Pines et al. (2014) US
Pilot interventional study
Descriptive longitudinal
Crombie et al. (2013) UK
Ethnographic case study
• Four training modules over two semesters. • The only measure within the SRP that had a significant result was that of necessitating • Otherwise no significant findings • No change in resilience score with the three year gap • Older students were found to have higher levels of resilience • Fostering resilience • Peer group support in clinical and class • Family as support structure
1
Pitt et al. (2014) AU
60 undergrad upper division nursing students Small faith based college South West US 138 entry level with repeated measures three years later at the end of the program
Stephens (2013) US
Concept clarification (Norris method)
1
Stephens (2012) US
Interventional repeated measures during a twitter intervention Pretest posttest quasi-experimental design
• • • •
Taylor et al. (2012) US
28 second year adult nursing students 2 clinical sites London and west of London Clarify the concept of resilience in nursing students 70 junior level students 2 state supported Universities 136 matched pairs undergrad, all levels but freshman Location not specified
•
• • Pines et al. (2012) US
Correlational
Carroll (2011) US
Phenomenological
166 generic BSN Jr and Sr level. South West US 11 undergrad students near graduation California
Hodges et al. (2005)
Theoretical
Focus on Parse's HBST
and scored high on a Sense of Coherence (SOC) tool. The SOC was used as a screening tool. It was found that family support was the most common occurring theme. An ethnographic case study conducted with students in their second year of a London based university found that resilience influenced rates of program completion (Crombie et al., 2013). Furthermore Carroll (2011) and Crombie et al. (2013) found that encouragement from parents, significant others, children, grandparents and in-laws fostered resilience in students. Of these, mothers were mentioned most often (Carroll, 2011). Friendships were also identified as important to resilience, especially integration into a supportive peer group within the nursing program (Carroll, 2011; Crombie et al., 2013). Lifelong friendships also contribute to resilience according to Carroll (2011). Examples of faculty support were illustrated in the interviews and determined to be valuable to student resilience (Carroll, 2011). These two qualitative studies found that family, peer, and faculty support impact resilience in students. To date, quantitative work has not been done to correlate resilience with these factors. Varying results have been found regarding the impact of time on resilience in students. In a descriptive study in England, researchers explored nursing student personal qualities of resilience in first semester freshman students and then again prior to graduation three years later (Pitt, Powis, Levett-Jones and Hunter, 2014). The results showed no statistical difference in resilience scores over time, but researchers noted that older students scored higher on resilience instruments than their younger counterparts (Pitt et al., 2014). In contrast, Taylor and Reyes (2012) measured resilience in relation to test scores. They found that two measures on the Wagnild and Young Resilience Scale had statistical significance between the beginning and end of a semester. The measurement of perseverance, and existential aloneness both increased over this time period (Taylor and Reyes, 2012). The increase in perseverance may be attributed to a student's sense of determination, while the existential aloneness may be related
• •
• • •
Operational definition Nursing student model Hypothesis Experimental group had increased resilience post but not at follow up Two subsets of the RS perseverance and existential aloneness had sig increases from beginning of semester to end, No difference in RS across the curriculum Significant moderate correlation of RS between grades on the 1st and last exam Resilience and empowerment were positively correlated Themes found: support, perseverance, autonomy, empathy, high expectations, sense of purpose, optimism, honesty, critical thinking Coaching role for faculty Reflection, connection, resilience Professional identity related to resilience
1
2
1 2
1 1
1
to their ability to reach within themselves to succeed (Taylor and Reyes, 2012). In contrast Stephens (2012) believed that cumulative success led to increased resilience. It is difficult to compare these studies because different instruments and methods were used, but overall the literature supports that the passage of time makes a difference in a student's measured level of resilience. There is a positive correlation between empowerment and resilience (Pines et al., 2012). This factor was only reported in one study. The researchers measured resilience in relation to empowerment and conflict management styles and found that students with high measures of empowerment had high levels of resilience. This may be beneficial in preparing students for handling conflicts in the workplace. Strategies to Promote Resilience in Nursing Students Three studies in this review approached the promotion of resilience in nursing students. Two are interventional studies (Pines et al., 2014; Stephens, 2012) and one is a theoretical paper that offers recommendations based on Parse's theory (Hodges et al., 2005). Strategies posited in these papers include reflection (Hodges et al., 2005), simulation and debriefing (Pines et al., 2014), and resilience messages delivered through twitter (Stephens, 2012). Each of these will be discussed separately because their methods and findings are diverse. It has been proposed that Parse's theory can be a framework for undergraduate education that can enhance professional identity and resilient nurses. A theoretical paper by Hodges et al. (2005) posits that nurse educators can develop resilience in students by teaching students to reflect and persevere in the face of conflict. Faculty can work with students to identify success and build upon them. They can assist students that are having a difficult day to refocus and view it as a challenge and as an opportunity to overcome barriers. By acknowledging professional stamina, students can be taught the value of determination. Reflection, connection and resilience were presented as a whole. Hodges et al.
L.J. Thomas, S.H. Revell / Nurse Education Today 36 (2016) 457–462 Table 3 Definitions and descriptions of resilience across the literature. Author
Definition/description
“Resilience consists of suffering and perseverance, working through emerging difficulties and integrating crisis experiences into one's sense of well being” (p. 550) Pines, Rauschhuber, Cook, Norgan, “Resilience is the ability of an individual to adjust to adversity, maintain equilibrium, Canchola, Rischardson and retain some control over the environment and Jones (2014) move in a positive direction.” (p. 86) Pines et al. (2012) “Resilience is the ability to bounce back. The personal attributes of resilient people include an internal locus of control, pro-social behavior, empathy, positive self image, optimism and the ability to organize daily responsibilities.” (p. 1483) Carroll (2011) “Resiliency refers to the construct that the nursing student way be equipped with internal qualities and/or be supported by external forces that promote academic success in spite of stressful circumstances. (p. 13) Stephens (2012) Ahern's definition of adolescent resilience is used for theoretical and conceptual congruence. Adolescent resilience as a “process of adaptation to risk that incorporates personal characteristics, family and social support, and community resources” (p. 3). Stephens (2013) “Nursing student resilience is an individualized process of development that occurs through the use of personal protective factors to successfully navigate perceived stress and adversities. Cumulative success lead to enhanced coping/adaptive abilities and well-being.” (p. 130) Taylor and Reyes (2012) “Resilience in individuals has been defined as the ability to rise above difficult situations; adapt better than expected in the face of significant adversity; and recover from difficulty and overcome adverse circumstances in one's life”. (p. 2) Hodges, Keeley and Grier (2005)
(2005) propose that reflection should be developed early in conjunction with other basic nursing skills. “Resilience can develop from intentional reflection, step by cumulative step” (Hodges et al., 2005, p.553). The act of writing allows a student a time away from the noise and busyness of practice to think and construct thoughts about nursing. Through the reflection, instructors have a window into what a student is experiencing and can navigate and support the student to build resilience (Hodges et al., 2005). A pilot study was conducted to evaluate the use of a resilience intervention with nursing students based on the “Reaching Out and Reaching In” curriculum. (Pines et al., 2014). This program has been successful in young children, adolescents and college students (Pines et al., 2014). The curriculum was adapted specifically for nursing students and topics included: principles of resiliency and behaviors of resilient nurses, professional empowerment strategies in the workplace, conflict management styles and teamwork training. Four modules were presented over two semesters consisting of class followed by simulation and debriefing. The purpose of the pilot was to evaluate whether nursing students who participated in resilience education would have increased resiliency scores at the end of the program. Resilience was measured with the Stress Resiliency Profile (SRP), empowerment and conflict management were also measured. There were no significant changes in resilience scores from pretest to posttest (Pines et al., 2014). This demonstrates the complexity required to enhance resilience in nursing students. Stephens (2012) conducted a study using twitter to deliver an educational intervention to enhance resilience in nursing students. This multisite study consisted of an experimental and control group, with resilience measured by The Connor-Davidson Resilience Scale using a
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pretest, posttest and follow-up design. The participants were junior level baccalaureate student's aged 19–23. Students in the experimental group received four educational messages or questions (tweets) each week that were intended to promote resilience. Students in the control group got four tweets with nursing trivia or basic nursing information. Like the Pines et al. study the intervention was “loosely” based on the “Reaching Out and Reaching In” curriculum. A different theme was highlighted each week. The themes included: social support, positive emotions, humor, knowledge of health behaviors, self-knowledge and effective coping. Questions included: What is your greatest strength? How does this help you? Who is the most positive influence in your life? What can you learn from him/her? If a student tweeted, other students could respond and have dialog but the researcher did not. Resilience scores initially increased between pretest and posttest, but then declined at follow up (Stephens, 2012). The pilot study done by Pines et al. (2014) does not provide detailed information regarding the educational sessions that were administered to students. This makes the comparison to the Stephens' (2013) study difficult. Stephens' (2013) research is a dissertation therefore great detail about the intervention was provided. The theoretical information developed by Hodges et al. (2005) is very interesting but has not been tested. This variation is a limitation to the integration of strategies to enhance resilience in nursing students. More work in both theoretical and interventional specific to nursing students needs to be done in the area of resilience.
Discussion The concept of resilience in nursing students is in its infancy. With the exception of one theoretical article that was written in 2005, the remaining work has been published within the last three years. Stephens (2013) constructed a definition and model through her concept analysis but thus far it has not been utilized or tested. It was hoped that through this review more description of resilience in nursing students would be evident, however that is not yet clear in the literature. This is a limitation. A well-tested definition would allow for clarity in the measurement of resilience. The use of a consistent definition can aid in the comparison of studies thus making the science stronger. This is a critical point in the literature that has not been well established. It would be beneficial to further examine factors that contribute to resilience in nursing students through qualitative research. Data gathered would either support Stephens' (2013) definition or further refine it. There are multiple studies that correlate resilience in relation to other variables, academic success, self-efficacy and empowerment but no studies provide an answer to the question; what variables impact resilience in nursing students? A quantitative descriptive study to answer this question would further define the concept of resilience as it relates to nursing students. Research has identified resilience as important for nurses which led to the notion of enhancing resilience in nursing students to better prepare them for their professional role (Hodges, Troyan and Keeley, 2010; Jackson et al., 2007; McAllister and McKinnon, 2009; Pines et al., 2012; Stephens, 2013). The two interventional studies reviewed utilized social media (Stephens, 2012) and classroom educational modules (Pines et al., 2014). Stephens' (2012) Twitter intervention initially demonstrated an increase in resilience at posttest, however when evaluated again one-month post the resilience scores had decreased. Pines et al. (2014) set of four modules over two semesters did not result in an increase in resilience measures. It could be said that the frequent short interventions in Stephens' (2012) study are more beneficial than more sporadic interventions over two semesters in the Pines' et al. (2014) study. A direction for further research may include short doses of interventions over a longer period of time to assess effectiveness. The time of delivery during a nursing program is also a consideration. Research that evaluates the effectiveness of enhancing resilience at various points of
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education would be valuable. Is an intervention more effective early or late in a nursing program? Reflection in relation to resilience is an interesting idea however formal research to investigate its connection is lacking. Davies (1995) conducted a grounded theory study over twenty years ago that demonstrated reflection as a strategy to reduce anxiety in students and facilitate active learning skills. Since that time reflection has been utilized in various ways within nursing education. From the theoretical work that Hodges et al. (2005) conducted paired with the effectiveness of this tool (Davies, 1995) it is reasonable to hypothesize that reflection can facilitate resilience in students. Hodges et al. (2005) recommend beginning reflection early in their education as students are learning other nursing skills. Reflection continues to be valuable for students after graduation. There is research evidence to support that reflection aids new graduates to assimilate the discrepancies between their perceived role and the reality of being a professional nurse. The outcome of this process is termed emotional labor (Hodges et al., 2008). Research exploring reflection in relation to a student's resilience and new graduate's resilience would expand knowledge in this area. Despite resilience in nursing students being a relatively new research topic, there is sufficient information in the literature to inform faculty how to promote resilience. Nurse educators are in a unique position to facilitate the development of resilience in the students they teach (Stephens, 2013). Student resilience is important to consider regardless of the role of the faculty. Faculty can coach students to draw upon their resources to overcome challenges faced (Hodges et al., 2005). The support of family, friends and faculty has been shown to impact student resilience and encouraging students to access these resources may be beneficial. Promoting students to think about previous times they overcame obstacles may help stimulate them to persevere and reach higher to overcome the struggles they are currently experiencing (Stephens, 2013). Instructors can help students reframe experiences, from viewing it negatively to seeing it as a learning experience (Hodges et al., 2005). By asking the questions, what did you learn? Has this experience made you more knowledgeable or stronger? (Stephens, 2013), nursing faculty can promote more resilient nurses. Nurse faculty are responsible to prepare students to be professional nurses in a healthcare environment that has been described as fast paced, chaotic and full of conflict (McAllister and McKinnon, 2009; Pines et al., 2014). Resilience plays a role in that preparation, because this concept has been identified as an essential element for nursing practice. According to Grafton, Gillespie and Henderson (2010) resilience positively impacts nurse satisfaction, retention and can enhance patient care. Therefore, nurse educators are challenged to incorporate resilience education into nursing curriculum (Hodges et al., 2005). As illustrated in this paper, resilience in nursing students needs to be expanded and incorporated into education. The importance of resilience has been demonstrated, but a stronger knowledge of what affects a student's level of resilience and how resilience can be enhanced is needed. In order to develop this further a clear definition of the concept in nursing students needs to be tested, and then used consistently. From this theoretical models can be developed and evaluated. Conclusion This integrative review provides information to nursing faculty about the concept of resilience in nursing students. Resilience can affect a student's perseverance, academic success and empowerment. Faculty guidance of the student into the role of professional nurse is crucial. Thus it is important to foster resilience in nursing students to prepare them for longevity in today's healthcare system.
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