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International Journal of Mental Health Nursing (2020) 29, 553–575 doi: 10.1111/inm.12721

R EVIEW A RTICLE
Nurse resilience: A concept analysis
Alannah L. Cooper,1,2 Janie A. Brown,1 Clare S. Rees1,3 and Gavin D. Leslie1
1 2
School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, St John of God Subiaco Hospital,
Subiaco, and 3School of Psychology, Curtin University, Perth, Western Australia, Australia

ABSTRACT: Nurse resilience is attracting increasing attention in research and practice.

Possession of a high level of resilience is cited as being crucial for nurses to succeed professionally
and manage workplace stressors. There is no agreed definition of nurse resilience. A concept
analysis was undertaken to examine nurse resilience using a priori selected analysis framework.
This concept analysis aims to systematically analyse resilience as it relates to nurses and establish
a working definition of nurse resilience. Sixty-nine papers met the search criteria for inclusion.
Key attributes of nurse resilience were social support, self-efficacy, work–life balance/self-care,
humour, optimism, and being realistic. Resilience enables nurses to positively adapt to stressors
and adversity. It is a complex and dynamic process which varies over time and context and
embodies both individual attributes and external resources. Sustaining nurse resilience requires
action and engagement from both individuals and organizations.
KEY WORDS: adversity, concept analysis, definition, nurses, resilience.

Hagen et al., 2017; Tofthagen et al., 2014). A recent

INTRODUCTION
study found the emotional labour of suppressing emo-
The stressful nature of nursing work places nurses at tions during interactions with patients negatively
increased risk of burnout, depression, anxiety, sec- affected the resilience of mental health nurses (Del-
ondary traumatic stress (STS), and suicide (Alderson gado et al., 2020).
et al., 2015; Craigie et al., 2015; Hegney et al., 2014; Moral distress can contribute to burnout and is
Khamisa et al., 2013). Like other health professionals when an individual is unable to act according to their
and emergency personnel, nurses are exposed to a wide core values due to internal and external restraints
variety of stressors including trauma, shift work, work- (Fumis et al., 2017; Rushton et al., 2015; Wagner,
place violence, and insufficient resources (Happell 2015). The nature of a nurses’ role, involves providing
et al., 2013; Hsieh et al., 2016; Mealer et al., 2017). continuous care and forming close relationships with
Specifically, in a mental health context, nurses are patients and families, placing them at increased risk of
exposed to unique stressors including witnessing compassion fatigue (CF) and burnout (Boyle, 2011; Jar-
patients inflict self-harm and caring for patients who rad et al., 2018). Protective factors which enable nurses
may attempt and complete suicide (Foster et al., 2020; to positively adapt in stressful work situations have
been reported. Personal resilience has been identified
as a key protective attribute in dealing with these cir-
Correspondence: Alannah L. Cooper, School of Nursing Mid-
wifery and Paramedicine, Curtin University, Kent Street, Bentley, cumstances (Cusack et al., 2016; Mealer, Jones et al.,
WA 6102, Australia. Email: [email protected] 2012b; Rushton et al., 2015). Maintenance of psycho-
Disclosure statement: No funding was received for this review.
Conflict of interest: None.
logical well-being and mental health are common out-
Authorship statement: Each named author has substantially con- come indicators of a resilient process following adverse
tributed to conducting the underlying research and developing or events (Foster et al., 2020; Gao et al., 2017; Itzhaki
reviewing this manuscript.
Alannah L. Cooper, BNurs (Hons). et al., 2015).
Janie A. Brown, BN, M.Ed, PhD. The origins of research in resilience stem from psy-
Clare S. Rees, BA (Hons), MPsych (Clinical), PhD.
Gavin D. Leslie, BAppSc, Post Grad Dip, (Clin Nurs), PhD.
chology, initially in children (Garmezy et al., 1984;
Accepted March 04 2020. Werner & Smith, 1982) and then in groups including

© 2020 Australian College of Mental Health Nurses Inc.

14470349, 2020, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/inm.12721 by Tel Aviv University, Wiley Online Library on [27/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
554 A. L. COOPER ET AL.

adults (Connor & Davidson, 2003; Liu et al., 2015), (1993), Walker and Avant (1995), Morse (1995), and
veterans (Elbogen et al., 2012; Pietrzak et al., 2014), Chinn and Kramer (1995). Walker and Avant’s (1995)
patients with chronic illness (Guest et al., 2015; Tan- model is the most widely applied in the literature (Fitz-
Kristanto & Kiropoulos, 2015), and trauma victims patrick & McCarthy, 2016) and has been further
(Anderson et al., 2012; Daniels et al., 2012). Most peo- updated and refined. Their approach uses an eight-step
ple are exposed to one or more life-threatening experi- process (Table 1) to guide a deeper understanding of a
ences (Southwick et al., 2014) as well as regular concept. These steps are iterative rather than sequential
stressors throughout their lifetime (Fletcher & Sarkar, (Walker & Avant, 2011). Using Walker and Avant’s
2013; Southwick et al., 2014). Understanding what method, an analysis of the critical attributes of resilience
facilitates resilience and positive adaptation may play related to nurses is presented. The antecedents and con-
an important role in improving mental health for peo- sequences are described, and model, borderline, and
ple across many contexts. contrary cases define the concept.
Resilience has been defined as a trait, a process and
an outcome (Fletcher & Sarkar, 2013). When consid-
AIM
ered as a personality trait, resilience is fixed and stable
over time whereas, when viewed as a dynamic process,
Concept and purpose
resilience can develop throughout life and vary across
context and time (Atkinson et al., 2009). Defining resili- Whilst resilience is increasingly being referred to and
ence as a trait originates in psychology when identifying explored in the nursing literature, there is no clear def-
the characteristics of resilient individuals was a focus inition of what resilience means for nurses (Aburn
(Fletcher & Sarkar, 2013; O’Dougherty-Wright et al., et al., 2016; Foster et al., 2019). The aim of this CA is
2013). Consideration of the more complex nature of
resilience gave rise to the view of a dynamic process TABLE 1 Adaptation of Walker and Avant (2011) steps of concept
where adaptive systems beyond individual characteristics analysis
interplay and affect individual resilience including bio-
Steps of concept analysis Description
logical, social, and cultural processes (O’Dougherty-
Wright et al., 2013). Definitions based on possessing a Select a concept Concept selection for analysis
high level of resilience focus on positive adaptation and Determine the aims or Focus on the purpose and intention of
purposes of analysis performing the CA
successful coping (Fletcher & Sarkar, 2013). Regardless
Identify all uses of the ‘. . .. Identify as many uses of the
of perspective, most definitions centre around adversity concept you can discover concept as you can find’ (Walker &
and positive adaptation (Fletcher & Sarkar, 2013). Avant, 2011, p.161)
Adversity is an unpleasant or difficult situation (English Determine the defining Establish the cluster of attributes most
Oxford Dictionary, 2018). Positive adaptation is ‘. . .the attributes frequently associated with the concept
Identify a model case ‘. . .an example of the use of the
processes by which individuals’ attain overall patterns of
concept that demonstrates all the
adjustment that represent unusually favourable develop- defining attributes of the concept’.
mental trajectories, given their background and available (Walker & Avant, 2011, p.163)
resources’ (Mahoney & Bergman, 2002, p. 197). Identify additional cases Used to illustrate what the concept is
Due to variations in any concept’s utilization across and is not. Borderline, related and
disciplines and contexts, clarity is required when contrary cases are frequently used
invented and illegitimate cases are not
employing a concept in nursing research (Baldwin, always required.
2008; Foley & Davis, 2017; Walker & Avant, 2011). Identify antecedents and Antecedents are ‘. . .events or incidents
Concept analysis (CA) is utilized to inform a precise consequences that must occur or be in place prior to
definition and provide mutual understanding (Foley & the occurrence of the concept.
Davis, 2017). Consequences are ‘. . .events or inci-
dents that occur as a result of occur-
rence of the concept’. (Walker &
DESIGN Avant, 2011, p.167)
Define empirical referents ‘. . .classes or categories of actual
Concept analysis is a precise and rigorous process, pio- phenomena that by their existence or
neered by the philosopher Wilson (1963), with the presence demonstrate the occurrence
of the concept’. (Walker & Avant,
methodology spreading across disciplines. In nursing,
2011, p.168)
CA emerged in models developed by Rodgers and Knafl

© 2020 Australian College of Mental Health Nurses Inc.

to inform a working definition of nurse resilience. An positive outcomes in children exposed to adversity
important potential implication of this study is that use (Bonanno, 2004). A number of definitions have been
of a consistent definition of resilience could guide offered for resilience in children including; ‘. . .the posi-
future research efforts in the area. By knowing the key tive pole of individual differences in people’s response
markers of nurse resilience, studies can be designed to stress and adversity’ (Rutter, 1987, p. 316) and ‘. . .a
that focus specifically on the measurement of these dynamic process encompassing positive adaptation
variables. within the context of significant adversity’ (Luthar
et al., 2000, p. 543).
The study of resilience moved beyond developmen-
Definitions and uses of the concept
tal and social–psychological studies when post-trau-
In order to fully understand resilience, all uses must be matic stress disorder (PTSD) as a diagnostic entity
considered including exploring literature outside of the arose in 1980 (Agaibi & Wilson, 2005). Research
discipline to avoid bias (Walker & Avant, 2011). focused on adults, examining responses to trauma and
the development of PTSD. Psychologists sought to
Primary definitions establish factors associated with vulnerability and resi-
The origin of the term resilience is in the Latin word lience to PTSD (Agaibi & Wilson, 2005; Zuckerman,
resilire meaning to ‘spring back’ (Online Etymology 1999). Studies focused on groups exposed to extreme
Dictionary, 2017). The English Oxford Dictionary trauma including war veterans (Bartone, 1999; Hendin
(2017) defines resilience as ‘the capacity to recover & Haas, 1984), prisoners of war (Gold et al., 2000;
quickly from difficulties; toughness’ or ‘the ability of a Kluznik et al., 1986), and holocaust survivors (Cohen
substance or object to spring back into shape; elastic- et al., 2002; Kahana et al., 1988). In the context of
ity’. Synonyms include flexibility, strength, pliability, acute trauma, resilient individuals are those that do
buoyancy, toughness, and hardiness and antonyms not develop PTSD (Hoge et al., 2007). Definitions of
include rigidity, fragility, vulnerability, and weakness resilience in adults include ‘Resilience embodies the
(English Oxford Dictionary, 2017). personal qualities that enable one to thrive in the face
In science, resilience refers to how easily a material of adversity’ (Connor & Davidson, 2003, p. 76) and
returns to its original shape after elastic deformation ‘. . . resilience reflects the ability to maintain a stable
(Gorse et al., 2012) or the rate that a system regains equilibrium’ (Bonanno, 2004, p. 20). Despite the risk
structure and function following stress or perturbation of psychopathology following trauma, most people
(Park & Allaby, 2017). In sport, resilience is a measure positively adapt and display resilience (Bonanno,
of a body’s resistance to deformation (Kent, 2006). In 2004). This acknowledgement of the commonality of
social ecology, resilience is the capacity of a system to resilience stimulated a move away from focusing on
absorb or withstand disturbances and reorganize whilst psychopathology and towards a positive paradigm (Pan
undergoing change yet retain the same structure, func- & Chan, 2007). The presence of resilience in individ-
tion, and identity (Walker et al., 2004). uals frequently exposed to adversity and how to foster
and maintain this has become an area of particular
Resilience in psychology interest.
In children research focused on how, when faced with A number of professionals including firefighters
significant adversities such as having a mother with (Carpenter et al., 2015; Kimbrel et al., 2011; Meyer
schizophrenia (Garmezy & Streitman, 1974), socioeco- et al., 2012), police officers (Gershon et al., 2009; Mart-
nomic disadvantage (Garmezy, 1991; Werner & Smith, inussen et al., 2007), air traffic controllers (Jou et al.,
1982), maltreatment (Cicchetti et al., 1993; Moran & 2013; Maier, 2011; Martinussen & Richardsen, 2006),
Eckenrode, 1992), chronic illness (Wells & Schwebel, and health professionals (Felton, 1998; Koinis et al.,
1987), or catastrophic life events (O’Dougherty-Wright 2015; Mealer, Jones et al., 2012b) are subjected to
et al., 1997) some were able to positively adapt and extreme levels of stress, adversity, and trauma at work
thrive. Studies focused on identifying characteristics or which can result in negative psychological outcomes.
attributes resilient individuals possess (Garmezy, 1991; The need to support individuals working in such areas
Kobasa et al., 1982; Rutter, 1987; Werner & Smith, is recognized, and resilience has been identified as a
1982). Examples include a supportive environment, key protective factor (Galatzer-levy et al., 2013; Lee
hardiness, good self-esteem, and an easy temperament. et al., 2014; Papazoglou & Andersen, 2014). Drawing
These protective factors are considered to foster on definitions offered in psychology in their study of

© 2020 Australian College of Mental Health Nurses Inc.

firefighters, Lee et al. (2014, p. 129) state ‘Resilience 1. Resilience in nurses not a main focus
can be defined as the ability to adapt and successfully 2. Student nurses
cope with acute or chronic adversity’. Galatzer-levy 3. All other health professionals*
et al. (2013, p. 545) cite the work of Bonanno (2004) 4. Patients or carers
identifying resilience as commonplace in police officers 5. Healthcare systems resilience
facing frequent exposure to potentially traumatic * due to similarities between nursing and midwifery
events: ‘. . . with the largest group being asymptomatic professions, papers describing both disciplines were
or having very low symptoms overtime, a pattern desig- included, those solely on midwives were excluded.
nated as resilience’. Included papers were read and analysed to discover
Positive psychology has been applied to explore how the attributes, antecedents, and consequences related
organizations can influence resilience and well-being of to resilience in nurses.
employees (Bakker & Schaufeli, 2008; Bardoel et al.,
2014; Youssef & Luthans, 2007) as can positive organi-
FINDINGS
zational behaviour (Bakker & Schaufeli, 2008). Condi-
tions and resources organizations can provide include
Resilience in nursing
social supports at work, employee assistance programs,
flexible work arrangements, reward and benefit systems, Nursing is a high stress profession facing increasing
development programmes, and work–life balance prac- pressures in a changing social and ethical context.
tices (Bardoel et al., 2014). Positive organizational beha- These pressures can lead to moral distress, CF, and
viour benefits employees and results in better outcomes burnout which negatively impact nurses and the
for organizations (Lengnick-Hall et al., 2011). There is patients under their care (Hegney et al., 2014; Mealer,
evidence that behaviours of nurse managers can affect Jones et al., 2012b; Rushton et al., 2015). The study
nurses’ well-being and their ability to provide quality and understanding of individual resilience in nurses
care (Adams et al., 2018) mirroring findings in other has become increasingly important. Whilst there is cur-
workplaces (Boddy, 2014; Chughtai et al., 2015). rently no universally agreed definition of resilience in
The definitions of resilience utilized in the context the nursing literature, a number of themes have been
of nursing research remain ill defined. Whilst the ori- identified ‘. . . rising above to overcome adversity, adap-
gins of the construct labelled ‘resilience’ arise from tation and adjustment, “ordinary magic”, good mental
developmental psychology, it is evident that the ability health as a proxy for resilience and the ability to
to be resilient is not limited to childhood. Like others, bounce back’ (Aburn et al., 2016, p. 984). The nursing
nurses are exposed to significant stressors and adversity literature has considered individual characteristics asso-
in the workplace that may be modulated by resilience ciated with resilience, resilience as a dynamic process,
but have the potential to cause stress, depression, or and resilience as an innate energy or motivating life
anxiety. force (Grafton et al., 2010). It is believed resilience can
be enhanced and modified in nurses and is therefore
not a fixed personality trait (Craigie et al., 2016; Foster
METHODS
et al., 2018a,b; Foureur et al., 2013; McDonald et al.,
2013; Mealer et al., 2014; Slatyer et al., 2018a). Resili-
Nursing literature search
ence of nurses has been studied in a variety of settings
In reviewing resilience literature relevant to nurses, the including mental health (Itzhaki et al., 2015; Matos
following electronic databases were searched from the et al., 2010; Prosser et al., 2017), intensive care (Mealer
date each was available to July 2019: CINHAL, MED- et al., 2017; Mealer, Jones et al., 2012b), oncology
LINE, and PSYCINFO. Terms used were resilienc* (Kutluturkan et al., 2016; Lim et al., 2016; Zander
AND nurs*. Titles and abstracts for all papers were et al., 2013), operating theatres (Gillespie et al., 2009;
reviewed to determine suitability, and reference lists of Gillespie et al., 2007), emergency departments (Flarity
retrieved articles were manually searched to identify et al., 2013; Hsieh et al., 2017; Tubbert, 2016), and
additional studies. Inclusion criteria captured qualita- aged care (Cameron & Brownie, 2010; Cope, Jones, &
tive studies, quantitative studies, discussion papers, and Hendricks, 2016c). There is agreement that resilience
reviews, in English, explicitly discussing or investigating is vital in enabling nurses to cope with workplace stress
resilience in nurses (Fig. 1). Exclusion criteria are and pressures (Hart et al., 2014; Hegney et al., 2015;
listed below: McAllister & McKinnon, 2009; Mealer, Jones et al.,

© 2020 Australian College of Mental Health Nurses Inc.

FIG. 1 Literature Search.

2012b; Tusaie & Dyer, 2004). Resilience is associated adapt, and recover from adversity. Delgado et al.
with the prevention of negative outcomes including (2017) viewed resilience in nursing as a personal capac-
burnout, CF, STS, depression, stress, and anxiety ity that helps nurses manage workplace adversity and
(Hegney et al., 2015; Kutluturkan et al., 2016; Lanz & demands. Definitions vary and no universal definition
Bruk-Lee, 2017; Manzano Garcıa & Ayala Calvo, 2012; from a nursing perspective has been established. To
Mealer et al., 2017; Mealer, Jones et al., 2012b; Rush- analyse the concept of resilience in relation to nurses,
ton et al., 2015). the defining attributes require deeper examination.
Numerous attributes associated with resilience in
nurses have been identified (Table 2). A variety of defi-
DEFINING ATTRIBUTES
nitions have been employed, often drawing on defini-
tions used in psychology. Pipe et al. (2012, p. 11) Determining the defining cluster of attributes most fre-
consider resilience to be ‘. . . the ability to adapt to quently associated with the concept is a crucial aspect
life’s ever-changing landscape and recover quickly from of the analysis (Walker & Avant, 2011). These help to
stressors and potential stressors’. The analogy of differentiate the concept of resilience from other con-
‘bouncing back’ is frequently employed in definitions of cepts. Numerous attributes of nurse resilience have
resilience in nursing (Aburn et al., 2016; Hart et al., been identified (Table 2). The defining attributes are
2014; Mealer et al., 2017; Tubbert, 2016). Wei and not exhaustive; however, they are based on analysis of
Taormina (2014) employed a more complex definition the literature of resilience in nurses. Six key defining
considering resilience as a multifaceted construct attributes most frequently cited in the literature are
including personal determination, the ability to endure, social support, self-efficacy, work–life balance/self-care,

© 2020 Australian College of Mental Health Nurses Inc.

TABLE 2 Literature utilized in concept analysis

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Tusaie and USA Historical Significant Optimism, intelligence, N/A Bouncing back, cope
Dyer. (2004) review stress or humour, social skills, wide successfully
adversity range of coping strategies,
perceived social support
Ablett et al. UK Qualitative Workplace High degree of commitment, Interviews Job satisfaction, maintenance
(2007) stress sense of purpose, hardiness, of well-being, staff retention,
sense of coherence, quality patient care
spirituality, work–life
balance, collegial support,
good social networks
Gillespie Australia Quantitative Adversity, Hope, self-efficacy, coping, Connor–Davidson Retention of nurses
et al. (2007) workplace control and competence Resilience Scale
stress (Connor & Davidson,
2003)
Jackson Australia Literature Adversity Positive and nurturing N/A Reduced vulnerability to
et al. (2007) review professional relationships, workplace adversity,
maintaining positivity, maintenance of normal
emotional insight, life functioning, retain nurses
balance and spirituality,
reflection
Gillespie Australia Quantitative Workplace Experience (more Connor–Davidson Ability to adapt or cope
et al. (2009) stress, experienced nurses had Resilience Scale
adversity higher resilience levels) (Connor & Davidson,
2003)
Glass (2009) Australia, Qualitative Adversity Hope, optimism, being Participant Intrapersonal strength,
New realistic, flexibility, observation, semi- personal growth, job
Zealand, adaptability, critical structured satisfaction, effective
UK and reflection, emotional conversational workplace practices, delivery
USA intelligence, self-care, social interviews art-based of quality health care
support, work–life balance reflections and
written reflections
McAllister Australia Literature Adversity Internal locus of control, N/A Development of coping
and review pro-social behaviour, skills, thrive in busy dynamic
McKinnon empathy, positive self-image, workplaces
(2009) optimism and the ability to
organize daily responsibilities
Cameron Australia Qualitative Adversity Collegial support, debriefing, Interviews Competent, skilful holistic
and Brownie work–life balance, self-care, care. Retention of
(2010) a sense of purpose, humour, workforce.
optimism and positive
thinking, strong social
support network, spiritual
practice, confidence,
personal satisfaction and
pride
Grafton Australia Literature Stress, Holistic self-care practices, N/A Enables nurses to better
et al. (2010) review adversity spiritual well-being manage responses to stress,
recover from or prevent
depletion of self and reduce
vulnerability to the impact
of future stress
Matos et al. USA Quantitative Adversity Positive professional status, The Resilience Scale Job satisfaction, protection
(2010) effective interpersonal (Wagnild & Young, against negative outcomes
relationships, communication 1993)

(Continued)

© 2020 Australian College of Mental Health Nurses Inc.

TABLE 2 (Continued)

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Koen et al. South Quantitative Workplace High levels of hope, The Resilience Scale Overcome adversity
(2011) Africa adversity optimism, coping self- (Wagnild & Young,
efficacy, sense of coherence 1993)
and flourishing mental health
Kornhaber Australia Qualitative Adversity Hardiness, emotional Interviews Retain nurses, transcend
and Wilson toughness, developing coping adversity, personal growth,
(2011) mechanisms, work–life sustain nurses through
balance, emotional difficult and challenging
detachment, natural working environments,
selection (an innate ability), improved outcomes for
nursing and multidisciplinary nurses and patients
team support, pragmatism,
determination, perseverance,
self-efficacy
Dolan et al. Australia Mixed Adversity, Sense of purpose, sense of The Resilience Scale Protection from negative
(2012) methods stress achievement, self-reliance, (Wagnild & Young, consequences such as
enjoyment in work, not 1993) burnout, ability to care
working shifts, emotional
distancing
Manzano Spain Quantitative Adversity Self-awareness, realistic Connor–Davidson Protection from emotional
Garcıa and expectations, positive Resilience Scale exhaustion and burnout,
Ayala Calvo emotions (Connor & Davidson, staff retention
(2012) 2003)
McDonald Australia Qualitative Adversity Peer support, reflection, Postintervention Positive supportive
et al. (2012) hardiness, positive outlook, interviews, workshop relationships and networks,
emotional intelligence, evaluations, field increased confidence,
intellectual flexibility, notes and research increased awareness, well-
creative and critical thinking, journals. being in the workplace and
work–life balance, spirituality other spheres, assertive
communication and conflict
resolution
Mealer et al. USA Quantitative Adversity Social support, engaging in Connor–Davidson Lower prevalence of post-
(2012a) relationships, safe workplace, Resilience Scale traumatic stress disorder and
higher general life (Connor & Davidson, burnout
satisfaction, engaging in fun 2003)
and leisure activities.
Mealer et al. USA Qualitative Extreme Spirituality, supportive social Telephone interviews Ability to continue to work
(2012b) stressors network, optimism, having a with highly resilient successfully in stressful ICU
resilient role model, nurses and nurses environment, prevent the
acceptance that death is part with PTSD development of PTSD,
of life, acceptance patient
outcome cannot be
controlled, humour,
emotional intelligence,
positive reframing, critical
reflection, viewing trauma as
a learning and/or growing
experience, engaging in
exercise, rituals
Pipe et al. USA Mixed Stress Positive approach, optimism, The Personal and Use of positive coping
(2012) methods positive coping skills Organizational strategies, enhanced well-
Quality Assessment – being, increased confidence,
Revised (POQ-R) empowerment, improved
physical health, staff
retention

(Continued)

© 2020 Australian College of Mental Health Nurses Inc.

TABLE 2 (Continued)

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Shirey USA Discussion Workplace Self-efficacy, hope, coping, N/A Positive adaptation, cognitive
(2012) paper change and confidence, hardiness, transformation, personal
adversity optimism, patience, control, personal growth in
tolerance, adaptability, a the wake of disruption, more
sense of humour, collegial readily accept change
support
Flarity et al. USA Quantitative Adverse Self-regulation, N/A Ability to bounce back or
(2013) circumstances intentionality, self-validation, thrive.
connection and support, self-
care and revitalization
Foureur Australia Mixed Stress Mindfulness N/A Increased health, decreased
et al. (2013) methods depression, anxiety and
stress, increased sense of
coherence
Lowe (2013) USA Literature Adversity Supportive social networks, N/A Successful adaptation,
review optimism, having a resilient protection against negative
role model, spirituality, self- psychological outcomes,
efficacy, a sense of humour, enhanced job satisfaction,
hope, adaptability/flexibility, decline in nurse turnover
caring and healthy work rates, ability to provide
environment, self-care compassionate, caring and
excellent care to patients
McAllister Australia Discussion Adversity Internal locus of control, N/A Positive adaptation, may
(2013) paper staying calm, sense of improve patient outcomes
humour, optimism, ability to and build a stronger
transcend, connectedness to profession
social/cultural/physical
environment, has a
repertoire of coping
mechanisms, generativity
McDonald Australia Qualitative Workplace Self-care, self-confidence, Interviews Increased assertiveness at
et al. (2013) adversity, self-awareness, creativity, work, more supportive
disruption, flexibility, hardiness, hope, communication, closer group
change resourcefulness, optimism, dynamic, increased
emotional insight, emotional collaborative capitol,
intelligence, positive outlook empowerment, increased job
satisfaction, increased
retention
Zander and Australia Qualitative Stress, Experience personal and Interviews Developing from past
Hutton negative professional, realistic view, experiences, ability to
(2013) situations, self-care, personal rituals, overcome negative
adversity, loss, emotional management and situations, use knowledge
hardship expression, talking, problem and adapt to new situations
solving, effective support,
insight, reflection, positive
attitude
Hart et al. USA Integrative Adversity Hardiness, self-efficacy, N/A Staff retention, ability to
(2014) review hope, optimism, collegial overcome challenge
support, humour, positive obstacles, increased quality
thinking, engaging in of life, better health,
extracurricular activities, effective use of adaptive
positive organizational coping strategies
culture in the workplace

(Continued)

© 2020 Australian College of Mental Health Nurses Inc.

TABLE 2 (Continued)

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Mealer et al. USA Mixed Trauma, stress Positive support systems, Connor–Davidson Mitigating the development
(2014) methods optimism, faith, cognitive Resilience Scale of common maladaptive
flexibility and self-care (Connor & Davidson, psychological symptoms
2003), written
exposure sessions
Wei and China Quantitative Stressors, Determination, endurance, Authors newly Career success
Taormina adversity adaptability, recuperbility, created resilience
(2014) conscientiousness, work–life measure
balance, higher educational
levels, good financial
resources (income), physical
wellness, Chinese values,
future orientation
Cline (2015) USA Discussion Adversity, Being realistic, self- N/A Longevity, success,
paper stress acceptance, hardiness, enhanced collegial
courage, collegial support, relationships and leadership
continued learning, capabilities, protect
willingness to fail, optimism, emotional and physical
positivity, emotional health, reduced absenteeism,
intelligence, self-care, work– increased job satisfaction,
life balance improved nurse retention,
patient safety and quality
outcomes
Dyess et al. USA Qualitative Adversity Self-care, fostering Interviews Staff retention, positive
(2015) relationships, work–life adaptation to change
balance, reflection,
accountability, finding
meaning and learning in all
situations
Gillman Australia Systematic Stressors Work–life balance, self- N/A Ability to thrive, coping, job
et al. (2015) review awareness, self-esteem, satisfaction
realistic expectations,
optimism, humour, support
Hegney Australia Quantitative High level Mindfulness, self-efficacy, Connor–Davidson Improved compassion
et al. (2015) stressors, adaptive coping behaviours Resilience Scale satisfaction
adversity (Connor & Davidson,
2003)
Itzhaki et al. Israel Quantitative Stress, Group resilience, collegial Connor–Davidson Higher staff resilience
(2015) workplace support Resilience Scale associated with increased life
violence (Connor & Davidson, satisfaction
2003)
Kim and Korea Qualitative Adversity Work–life balance, positive Interviews Positive coping
Windsor thinking, flexibility, assuming
(2015) responsibility, self-esteem,
family support
Leverance USA Brief Adversity, Optimism, mindfulness, N/A Reduce burnout, prevent
(2015) discussion stressors social support, spiritual compassion fatigue,
paper practices, realistic outlook, improved patient care
self-care, mentorship, self-
reflection, humour

(Continued)

© 2020 Australian College of Mental Health Nurses Inc.

TABLE 2 (Continued)

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Rushton USA Quantitative Stress Hope, self-efficacy and Connor–Davidson Protection from emotional
et al. (2015) coping, external activities Resilience Scale exhaustion and increased
such as developing problem- (Connor & Davidson, personal accomplishment,
solving skills or engaging in 2003) reduced stress
work, prayer, exercise, play
or art.
Shimoinaba Japan Qualitative Negative Self-nurturing, self- Face-to-face in-depth High-quality care for
et al. (2015) situations or awareness, accepting interviews patients and families, a
adversity professional limitations, sense of mastery, effective
validating care (receiving coping skills
feedback), coping adaptively,
support from others
Turner and USA Conceptual Adversity, Social support, positive N/A Overcome adversity,
Kaylor framework stressors professional relationships, embrace change,
(2015) work–life balance, reflection, maintenance of health/well-
emotional control, exercise, being
humour, spirituality, self-care
Brown et al. Australia Systematic Acute or Passion for work, engaging N/A Enable a sustainable
(2016) review chronic in professional development, workforce, sense of
threats to maintaining a work–life empowerment, cope better
personal well- balance, good social supports with work stressors, achieve
being, optimal patient outcomes
stressors,
adversity
Cope et al. Australia Qualitative Adversity, Self-control, self-efficacy, Field notes, memos, Positive adaptation, ability to
(2016a) negative optimism, hope, leadership, gesture drawings and cope, maintenance of normal
effects of valuing social support, interviews function, resist and absorb
workforce humour, emotional the impact of events, remain
challenge and endurance, positive attitudes, working, perform care,
stress self-set goals, self-motivation, advocate, teach
perseverance
Cope et al. Australia Qualitative Adversity Self-control, self-care, Interviews Positive change and
(2016b) emotional intelligence, adaptation, perform
staying positive, reflection, effectively, retain nurses,
hope, humour, valuing social protect nurses
support, paying it forward
(undertaking acts of
kindness), passion for the
profession, taking on
challenges, pride,
perseverance, experiencing
adversity and growing
through it, good leadership
Cope et al. Australia Qualitative Workplace Self-control, self-care, Interviews Ability to survive and thrive,
(2016c) adversity reflection, hope, humour, positive adjustment, sustain
positivity, work–life balance, well-being, job satisfaction,
strong social networks staff retention, improved
(family, friends and patient safety outcomes
colleagues), professional
pride, sense of purpose,
enjoyment in taking on a
challenge, optimism

(Continued)

© 2020 Australian College of Mental Health Nurses Inc.

TABLE 2 (Continued)

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Craigie Australia Quantitative Stress, Self-efficacy, positive coping Connor–Davidson Adaptive coping to stress
et al. (2016) adversity, Resilience Scale
trauma, (Connor & Davidson,
tragedy, 2003)
threats
Cusack Australia, Theoretical Adversity Self-efficacy, coping, N/A Staff retention, quality
et al. (2016) Brazil, model mindfulness patient care, reduction of
China burnout, compassion fatigue
and workplace distress
Hsieh et al. Taiwan Quantitative Workplace Extraversion, peer support, The Resilience Scale Maintenance of equilibrium,
(2016) violence, work–life balance for Adults (Friborg positive coping
traumatic et al., 2003)
events,
adversity
Hudgins USA Quantitative Adversity Optimism, self-confidence, Connor–Davidson Increased job satisfaction,
(2016) work and personal support Resilience Scale retention
networks, empowerment, (Connor & Davidson,
spirituality/sense of purpose, 2003)
self-awareness
Kutluturkan Turkey Quantitative Stressors Having children, higher The Resilience Scale Increased personal
et al. (2016) educational level, social for Adults (Friborg accomplishments, prevent
support resources, age et al., 2003) burnout and emotional
(older) exhaustion
Lim et al. Singapore Quantitative Adversity, Self-efficacy, communication The Resilience Scale Reduction in stress, improve
(2016) change or risk skills (Wagnild & Young, patient care
1993)
McDonald Australia Qualitative Workplace Collegial support, support Interviews Job satisfaction, feelings of
et al. (2016) adversity from family and friends, self- competence, improve patient
care, self-motivation, care, reduced stress,
autonomy, optimism, self- potential career advantage
efficacy, confidence
Tubbert USA Qualitative Stress, Flexible and creative Interviews Ability to cope with stress,
(2016) adversity thinking, decisiveness, engaged workforce,
tenacity, interpersonal increased job satisfaction
connectedness (social
supports), honesty, self-
control, optimism
Williams Canada Quantitative Adverse Self-efficacy, hope, coping, The Resilience Scale Better quality of care,
et al. (2016) events, stress competency, hardiness for Adults (Friborg increased respect for
et al., 2003) patients
Brennan UK Discussion Adversity Self-confidence, N/A Positive adaptation and
(2017) paper resourcefulness, curiosity, coping, assists nurses to
self-discipline, level- deliver high-quality care and
headedness, flexibility, succeed professionally
problem solving ability,
emotional stamina,
intelligence and a strong
sense of self
Delgado Australia Integrative Challenging Optimism, sense of purpose, N/A Reduction in workplace
et al. (2017) review circumstances faith/belief, sense of self, stress, prevent negative,
or adversity empathy, insight, self-care, psychosocial outcomes,
hope, self-efficacy, increased well-being
adaptability, emotional
intelligence

(Continued)

© 2020 Australian College of Mental Health Nurses Inc.

TABLE 2 (Continued)

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Gao et al. China Quantitative Adversity, Social support, confidence Connor–Davidson Reduction in negative
(2017) trauma Resilience Scale psychological outcomes,
(Connor & Davidson, higher general well-being,
2003) positive adaptation
Guo et al. China Quantitative Workplace Self-efficacy, education, Connor–Davidson Positive adaptation,
(2017) adversity positive coping style, Resilience Scale increased job satisfaction
lifestyle, i.e. cigarette use (Connor & Davidson,
and exercise (nonsmokers 2003)
had higher resilience levels,
those who exercised had
higher resilience)
Hsieh et al Taiwan Quantitative Adversity Higher level of education, The Resilience Scale Ability to deal with violent
(2017) seniority, extraversion, family for Adults (Friborg events, improve safety and
support, peer support et al., 2003) sense of well-being
Lanz and USA Quantitative Adversity Positive emotions, emotional The Resilience Scale Ability to bounce back after
Bruk-Lee control (Wagnild & Young, experiencing conflict in the
(2017) 1993) workplace, reduction in
negative effects of social
stressors
Marie et al. Palestine Qualitative Adversity Facing challenges, being Interviews and Successful coping skills
(2017) steadfast, commitment, observational data
religion, love for the
profession, supportive
relationships (family,
friends), supportive
managers and colleagues,
education, sense of purpose,
experience, tenacity, self-
confidence
Mealer et al. USA Quantitative Adversity Optimism, humour, engaging Connor–Davidson Reduced risk of PTSD
(2017) the support of others, Resilience Scale
personal competence, (Connor & Davidson,
leadership, perseverance 2003)
Prosser Canada Qualitative Adversity Having a vast perspective, Face to face semi- Ability to thrive and provide
et al. (2017) having realistic expectations, structured interviews care
expert of self (self-nuturance
and self-awareness), clarity
in belief systems, being
present through staying
awake
Wang et al. China Quantitative Adversity, Friend and co-worker Connor–Davidson Reduce turnover
(2017) stress, trauma, support, self-efficacy, Resilience Scale
threat, positive work climate, (Connor & Davidson,
deprivation tenacity, strength, optimism 2003)
Zheng et al. Singapore Quantitative Workplace Age (older), experience The Resilience Scale Increased job satisfaction,
(2017) stress (more years), higher (Wagnild & Young, staff retention, adaptive
education levels, religion, 1993) behaviour
work–life balance
Ang et al. Singapore Quantitative Adversity Being married or having Connor–Davidson Retention of nurses
(2018) been married in the past, Resilience Scale
older age, more years of (Connor & Davidson,
experience, higher 2003)
educational levels, self-
efficacy

(Continued)

TABLE 2 (Continued)

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Brown et al. Literature Adversity Optimism, self-efficacy, N/A Reduction in negative

(2018) review hope, flexibility psychological outcomes
Foster et al. Australia Qualitative Adversity, Peer support, organizational Focus groups and Reduction on negative
(2018a,b) workplace support, education, reflection interviews psychological outcomes,
stressors improved patient care,
increased job satisfaction,
increased self-esteem
Foster et al. Australia Quantitative Adversity, Education, good Workplace Resilience Reduction in negative
(2018a,b) stressors relationships, interpersonal Inventory (McLarnon psychological outcomes,
and communication skills & Rothstein, 2013) increased well-being
Slatyer et al. Australia Qualitative Adversity, Mindfulness, self-care Interviews Staff retention, reduction in
(2018b) trauma, negative psychological
tragedy, outcomes
threats or
significant
sources of
stress
Slatyer et al. Australia Quantitative Adversity, Mindfulness, self-care, social Connor–Davidson Reduced burnout and
(2018a) trauma, support Resilience Scale depressed mood, improved
tragedy, (Connor & Davidson, compassion satisfaction and
threats or 2003) quality of life
significant
sources of
stress
Babanataj Iran Quantitative Adversity, Education and training, Positive adaptation, personal
et al. (2019) difficulties and internal and external promotion and growth,
hardships of supports reduction in occupational
life, and stress
occupation

humour, optimism, and being realistic. These attributes nonwork activities but can vary over time and is the per-
are described in detail below: ception that work and nonwork activities are compatible
1) Social support: Social supports promoting resili- (Kalliath & Brough, 2008). Self-care is when an individ-
ence in nurses were frequently identified in the litera- ual actively practices protecting their well-being and
ture. Effective social support results in individuals happiness. This encompasses practices which maintain
feeling valued, cared for, and provides a sense of and protect both physical and mental well-being (Orem,
belonging (Cobb, 1976). Nurses can draw on social 1985). Self-care includes a wide range of activities
support from colleagues, managers, friends, and fami- including exercise, good nutrition, mindfulness, medita-
lies. Individuals need to engage with social supports, tion, and socializing (Richards et al., 2010).
and workplaces can provide support systems and foster 4) Humour: The ability to make light of adversity
positive collegial relationships. through humour has long been recognized as a way in
2) Self-efficacy: Self-efficacy refers to an individual’s which nurses and other health professionals cope with
belief in their ability to succeed in a given situation or workplace stress (Wanzer et al., 2005). Humour can
activity (Bandura, 1978). An individual’s perception of foster relationships with colleagues and patients
self-efficacy will influence the activities they engage in enabling teamwork, relieving tension (Dean & Major,
and those with higher levels of self-efficacy are more 2008) and improving experiences ( Astedt-Kurki &
likely to persevere and succeed (Bandura, 1978). Isola, 2001; Tanay et al., 2014).
3) Work–life balance/self-care: Achieving work–life 5) Optimism: Optimism is the extent to which indi-
balance and self-care is crucial to well-being. Work–life viduals hold favourable expectations for the future and
balance is the division of an individual’s time between is linked to increased levels of coping and better physi-
work and family or leisure activities. Work–life balance cal health, whereas pessimism is the expectation that
does not mean time is equally divided between work and bad things will happen (Carver et al., 2010). Hope is

related to optimism but differs as it is a feeling of her personal life. Sarah will often de-brief with col-
expectation or desire for a particular thing to happen leagues formally in facilitated de-brief sessions, if there
rather than a general favourable outlook (Bryant & has been a particularly traumatic event, and informally,
Cvengros, 2004). There is evidence that positive emo- going out with colleagues after work. The organization
tions may sustain psychological resilience (Fredrickson, Sarah works for provides access to counselling and sup-
2001). In nurses, optimism is often discussed in the port. She also has the support of family and friends
context of remaining positive and looking for the posi- who she shares her feelings and experiences with.
tive in adversity (Hart et al., 2014; Jackson et al., 2007; Sarah can rely on her sense of humour in difficult situ-
McDonald et al., 2012; Pipe et al., 2012). ations and will take away the positive in any situation,
6) Being realistic: Nurses also need to be realistic as remaining optimistic. Sarah has a realistic outlook and
clearly not all situations they encounter have positive acknowledges every patient’s experience and recovery
outcomes. Being realistic can be described as having a journey differs. Sarah maintains her work–life balance,
practical and sensible idea of what can be achieved or making time to do things she enjoys outside of work
expected. This includes reframing experiences, having including practising mindfulness, exercise, travel, and
realistic expectations about caregiving, cultivating a socializing.
realistic perspective on life and realistic goal setting
(Cline, 2015; Gillman et al., 2015; Leverance, 2015;
Borderline case
Prosser et al., 2017; Zander et al, 2013). Being realistic
is important because unrealistic optimism has potential The following constructed borderline case provides an
negative consequences for physical and psychological example where most of the attributes of resilience are
well-being (Shepperd et al., 2017). present.
Angela is a RN on a surgical ward. She cares for
high acuity patients and resource, and skill mix issues
CASE STUDIES
occur frequently. Angela is confident and competent
The defining attributes of resilience can now be caring for surgical patients although she becomes ‘flus-
employed to construct model, borderline, and contrary tered’ if things do not quite go according to her shift
cases. Walker and Avant (2011) indicate these can be plan. She is expected to co-ordinate on the ward, a role
from real life, constructed or in the literature. The pur- the organization has not prepared her for or provided
pose of the cases is to demonstrate what the concept is support for. She gets on well with colleagues and has a
and is not by the presence or absence of the defining supportive family. Angela has an active social life, mak-
attributes. In order to demonstrate all attributes, it is ing time for life outside of work. Angela likes routine
common to use constructed case studies (Earvolino- where she can stick to her care plan for the shift.
ramirez, 2007; Vazquez-Calatayud et al., 2017; Wang, When there are unexpected complications or poor out-
2004). The presented cases reflect the adversity and comes, she feels responsible for the consequences
stressors nurses can face in their daily work and the although they are often outside her control. This leaves
context in which nurse resilience has been explored in Angela feeling stressed and anxious for a time.
the literature.
Contrary case
Model Case
The following constructed contrary case provides an
The following constructed model case presents a example of where the attributes of resilience are not
‘. . .pure case of the concept,. . .’ (Walker & Avant, present.
2011, p. 163). Joe is a RN working on a medical ward which is
Sarah is a registered nurse (RN) working on an often poorly staffed and does not have an adequate
acute psychiatric ward. Each day she faces numerous skill mix. Some patients are confused and can be
stressors including caring for high acuity patients, skill aggressive towards staff. Joe cares for patients who are
mix, and resourcing issues, traumatic situations includ- dying. Although Joe is a RN he does not feel confident
ing patient self-harm and suicide attempts, and work- in his abilities and feels pessimistic about his work.
place violence. Sarah is an experienced RN confident Frequently, Joe has trouble completing the tasks on his
in her abilities, demonstrating a high level of self-effi- plan. The organization Joe works for has few supports
cacy. She has effective social support at work and in in place for staff. Joe does not engage with his

colleagues nor does he discuss the stresses of work and measured (Walker & Avant, 2011). A number of
with family or friends. Joe often calls in sick, and after scales have been designed to measure individual resili-
stressful days at work, he will isolate himself and drink ence by measuring the attributes associated with resili-
alone. He often thinks of leaving the nursing profession ence. The Connor–Davidson Resilience Scale (CD-
but is not sure what he would do instead. RISC; Connor & Davidson, 2003) is a 25-item scale
which is a multidimensional measure and draws on
numerous attributes (Table 3). The CD-RISC has been
ANTECEDENTS
used across a variety of populations and studies mea-
Antecedents are the events or incidents that must occur suring resilience in nurses (Gillespie et al., 2009; Guo
prior to the occurrence of the concept (Walker & et al., 2017; Hudgins, 2016; Manzano Garcıa & Ayala
Avant, 2011). The main antecedent for resilience is Calvo, 2012; Mealer, Jones et al., 2012b; Rushton
adversity. In order for an individual to employ and et al., 2015; Russo et al., 2018). Five of the six key
demonstrate resilience, significant stressors must be attributes identified in nurses are included in the CD-
encountered which contribute to the experience of RISC (Connor & Davidson, 2003). These attributes are
adversity. Nurses frequently encounter significant also measurable with a variety of other tools including
adversity in their work including exposure to traumatic self-efficacy (Chen et al., 2001; Sherer et al., 1982),
situations (Mealer et al., 2017; Morrison & Korol, optimism (Scheier et al., 1994), social support (Sarason
2014), shift work (Happell et al., 2013; Zander et al., et al., 1983), and humour (Martin & Lefcourt, 1984;
2013), workplace violence (Hsieh et al., 2016; Koen Thorson & Powell, 1991). The attribute of work–life
et al., 2011), staff shortages (Koen et al., 2011; McDon- balance/self-care is not included in the CD-RISC but
ald et al., 2013; Zander et al., 2013), skill mix issues other tools do exist to measure these such as the Mind-
(Happell et al., 2013; Zander et al., 2013), poor remu- ful Self-Care Scale (Cook-Cottone & Guyker, 2018)
neration (Khamisa et al., 2013; Koen et al., 2011; which encompasses physical and psychological self-care
McHugh et al., 2011), gender inequalities (Evans, 1997; and considers work–life balance.
Williams, 2013), interprofessional conflict (Lanz &
Bruk-Lee, 2017), patient acuity (Cope, Jones, & Hen-
Working definition
dricks, 2016a), and death and dying (Lanz & Bruk-Lee,
2017; Mealer et al., 2017; Shimoinaba et al., 2015). The nature of nurses’ work is characterized by extended
Although these are not unique to nurses, the level of interpersonal contact and direct involvement in delivery
exposure to patients through direct involvement in care of patient care having the potential to create stress and
and extended interpersonal contact is unique to the adversity demanding interpersonal resilience. This CA
profession (Boyle, 2011; Jarrad et al., 2018). has identified that resilience is vital in enabling nurses
to positively adapt. There are a number of antecedents,
defining attributes and consequences that contribute to
CONSEQUENCES
nurse resilience (Fig. 2). Based on the CA presented,
Consequences are the events or incidents that result we propose the following definition:
from the occurrence of the concept. The most cited Resilience is a complex and dynamic process which
consequences of possessing resilience in the literature when present and sustained enables nurses to positively
are the prevention of negative psychological outcomes, adapt to workplace stressors, avoid psychological harm
increased job satisfaction, remaining in the workforce and continue to provide safe, high-quality patient care.
and increased quality of patient care (Table 2). These To sustain resilience, nurses need to draw upon
consequences are important given the global predic- their own resources (including family, friends, and col-
tions of nursing shortages which will adversely impact leagues) and have organizational conditions and sup-
care quality (World Health Organization, 2013). The port which promote resilience. Without the
attributes associated with resilience enable nurses to combination of personal attributes, social, and work-
adapt and bounce back. place support, nurses will face difficulty in continuing
in the profession and are likely to leave employment or
worse, suffer psychological harm. If steps to sustain
EMPIRICAL REFERENTS
nurse resilience are not taken, it is likely that nursing
The final step of CA is determining the empirical refer- shortages will be further exacerbated resulting in
ents by which the defining attributes can be recognized poorer health outcomes for patients.

TABLE 3 Characteristics of Resilient People identified by Connor described consequence of possessing high levels of
and Davidson (2003) resilience is the prevention of negative psychological
View change or stress as a challenge/opportunity outcomes (Table 2). This includes the prevention or
Commitment reduction of symptoms of burnout, depression and anx-
Recognition of limits to control
iety which nurses can experience as a result of their
Engaging the support of others
Close, secure attachments to others work (Hegney et al., 2015; Kutluturkan et al., 2016;
Personal or collective goals Lanz & Bruk-Lee, 2017; Manzano Garcıa & Ayala
Self-efficacy Calvo, 2012; Mealer et al., 2017; Mealer, Jones et al.,
Strengthening effect of stress 2012b; Rushton et al., 2015). As well as being consid-
Past successes
ered as a protective factor, it is suggested resilience
Realistic sense of control/having choices
Sense of humour also results in benefits for nurses, organizations and
Action-orientated approach patients, with increased job satisfaction, staff retention
Patience and increased quality of patient care (Table 2). Resili-
Tolerance of negative effect ent processes are also associated with positive individ-
Adaptability to change
ual outcomes including the maintenance of
Optimism
Faith psychological well-being and mental health (Foster
et al., 2020; Gao et al., 2017; Itzhaki et al., 2015).
It is evident the literature to date has focused pri-
marily on the actions individual nurses can take to
DISCUSSION
develop and sustain resilience. This approach has
Clearly, nurse resilience is gaining increasing attention recently been questioned and criticized as an incom-
in both research and practice illustrated by the large plete because it largely ignores the working conditions
number of publications exploring the topic in recent nurses endure which can place them at risk (Foster
years. Gaining an understanding of resilience and how et al, 2019; Taylor, 2019; Traynor, 2017; Virkstis et al.,
to sustain nurse resilience is viewed as an essential 2018). A more comprehensive approach to sustaining
requirement for the nursing profession. This move resilience in nurses is needed including consideration
towards a focus on protective factors is in distinct con- of the role organizations can play in promoting resili-
trast to earlier research which concentrated on the ence of nurses under their employment. The scope and
potential negative outcomes of working as a nurse understanding of factors which affect nurse resilience
(Cusack et al., 2016; Mealer, Jones et al., 2012b; Rush- beyond an internal locus is needed to fully optimize
ton et al., 2015). Given the increasing pressures faced resilience research and resulting interventions.
by the nursing profession including nursing shortages,
reducing resources and increasing patient complexity
CONCLUSION
and acuity this shift in focus is needed (Cope, Jones, &
Hendricks, 2016a; Koen et al., 2011; McDonald et al., In this paper, we have provided a working definition of
2013; Zander et al., 2013). Finding solutions to the nurse resilience that has been empirically derived. The
challenges nurses face is crucial, promoting and sus- six key attributes that define nurse resilience provide a
taining nurse resilience could potentially play a role in useful framework to guide future research in the area.
supporting nurses and avoiding harm. Until now, research investigating nurse resilience is dif-
Through the process of concept analysis, a detailed ficult to interpret due to the use of a multitude of dif-
description of resilience specific to nurses has been ferent terms and concepts. We believe that a unified
drawn. The six key defining attributes incorporate definition of resilience in the nursing profession will
internal and external factors which are cited as promot- enable a more consistent understanding to guide
ing nurse resilience. The use of case studies assists in research and interpretation to practice.
the demonstration of the concept of resilience specific
to nurses applying the presence or absences of the
RELEVANCE FOR CLINICAL PRACTICE
attributes in a clinical context. The clinical working
environment is associated with adversity and stressors Resilience is needed to successfully adapt and prosper
(Happell et al., 2013; Hsieh et al., 2016; Mealer et al., as a nurse in clinical practice. Understanding resilience
2017) which are antecedents for resilience and are in the context of nurses and the factors which affect
reflected in the case studies presented. A frequently nurse resilience are critical to the development of

FIG. 2 The concept of resilience in nurses. [Colour figure can be viewed at wileyonlinelibrary.com]

effective research, policies, interventions, and work the risk of psychological harm and promote the well-
environments to protect nurse well-being, retain nurses being of mental health nurses.
in the profession and ensure the provision of quality
care. Organizations need to develop and provide strate-
ACKNOWLEDGEMENTS
gies which promote and sustain resilience in mental
health nurses. Given the complexity of nurse resilience, We would like to acknowledge Dr Shirley McGough
multifaceted approaches are needed which consider for her critical review of the manuscript.
the unique stressors mental health nurses encounter
and include changes to work environment and condi-
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Int J Mental Health Nurs - 2020 - Cooper - Nurse Resilience A Concept Analysis

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Int J Mental Health Nurs - 2020 - Cooper - Nurse Resilience A Concept Analysis

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ABSTRACT: Nurse resilience is attracting increasing attention in research and practice.

Hagen et al., 2017; Tofthagen et al., 2014). A recent

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

FIG. 1 Literature Search.

© 2020 Australian College of Mental Health Nurses Inc.

TABLE 2 Literature utilized in concept analysis

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

© 2020 Australian College of Mental Health Nurses Inc.

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

© 2020 Australian College of Mental Health Nurses Inc.

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

© 2020 Australian College of Mental Health Nurses Inc.

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

© 2020 Australian College of Mental Health Nurses Inc.

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

© 2020 Australian College of Mental Health Nurses Inc.

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

© 2020 Australian College of Mental Health Nurses Inc.

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

© 2020 Australian College of Mental Health Nurses Inc.

Authors Country Design Antecedents Defining attributes Empirical referents Consequences

Brown et al. Literature Adversity Optimism, self-efficacy, N/A Reduction in negative

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

© 2020 Australian College of Mental Health Nurses Inc.

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