Resilience as a strategy for struggling against challenges related to the nursing profession

Emel Bahad?r Y?lmaz

Giresun University,Health Sciences Faculty,Piraziz,Giresun 28340,Turkey

Resilience as a strategy for struggling against challenges related to the nursing profession

Emel Bahad?r Y?lmaz

Giresun University,Health Sciences Faculty,Piraziz,Giresun 28340,Turkey

a r t i c l e i n f o

Article history:

Nursing profession

Stress

Coping

Resilience

Stressors,such as work overload,role con flicts,lack of time,lack of self-care,poor job-related interpersonal relationships,feeling powerless to provide quality care,struggling with competing demands, death,con flict with doctors,peers and supervisors,and inadequate emotional preparation,can be negative,stressful,traumatic,or dif fi cult situations or episodes of hardship for nurses.Situations or episodes of these types can also cause both physical and mental problems,such as fatigue,irritability, lack of concentration,unhappiness,depressive sensation,depersonalization,and emotional exhaustion. Despite all of these challenges,resilience enables nurses to cope with their work environment and to maintain healthy and stable psychological functioning.The aim of this review is to describe the concept of resilience,explain characteristics with which it is related and outline interventions to increase the resilience of nurses.

?2017 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction

“Rising patient acuity,rapid assessments and discharges,and increased service use by clients mean that nurses are dealing with sicker people who are likely to have multiple conditions that may complicate both the treatment and the recovery.These pressures can lead to work-role overload and burnout.”1The problems related to workplace adversity can be negative,stressful,traumatic, resulting in dif fi cult situations or episodes of hardship for nurses.2Despite all of these challenges,resilience enables nurses to cope with their work environment and to maintain healthy and stable psychologicalfunctioning.3Resilience is the ability to bounce back or cope successfully despite substantialadversity.4Resilient nurses would learn to overcome these dif fi culties and develop better coping mechanisms to address stress through exposure to dif fi cult working situations and environments.5Therefore,this study aims to give insight on the de fi nition ofresilience and its characteristics, its meaning for nursing and how resilience ofnursing professionals might be improved within nurse clinicians,nurse managers,and nurse educators nurses.

2.De fi nition of resilience

The notion of resilience comes from Latin“resilire”and is de fi ned as the skillto overcome/become adapted to highly dif fi cult circumstances.4,6,7Resilience is mentioned as a developmental process as much as an individual characteristic.8,9Moreover,resilience is also de fi ned as the survivalof an individualfrom a disease or a loss,and the skillto survive.10,11No matter which one of these de fi nitions,in order to recognize that there is resilience,a dif fi cult event would have occurred,and the individualbecame adapted to this event.7

Resilience research has fi rst focused on children,youth and families.12In these studies,the aim was to grasp and explore the agents contributing to the health ofvulnerable children and youth, as wellas individual,familialand socialagents and developmental processes.Several conclusions have been drawn regarding resilience.First,there are certain characteristics that contribute to the success of children who are born and raised in disadvantaged circumstances.These developmental results that are better than expected address resilience.Second,the ability to cope well under stress is also addressed by resilience.Third,resilience may be a very positive in fluence that contributes to recovery from trauma. Therefore,it is possible to propose that resilience is related to posttraumatic growth and development.

Masten and Obradovic13stated that resilience could be de fi ned as being related to every type of word which is a positive component of the process for adapting to dif fi culties.Studies carried out accordingly have tried to de fi ne resilience mostly with dealing with stress,competence,emotional intelligence,optimism,sense of humor,patience,tolerance,belief and self-esteem.8,9,14e17It was also mentioned that cognitive and problem-oriented coping skills are important precursors of resilience.18

Earvolino-Ramirez4attempted to de fi ne resilience with several characteristics for us to understand it better.These characteristics include positive relationships or social support the individual has the individual's flexibility,aim or expectations in life,positive selfesteem or self-ef fi cacy and sense of humor.In addition to these characteristics,Fadardi et al.19mentioned that since resilient individuals have better mentalhealth and self-regulatory skills,with higher self-respect,they have more family support and less risky orientations such as drug use.

Resilience is a protective factor and consists of certain characteristics,such as a sense of carrying on,enduring values,problemsolving,appreciation for interaction with others and comfort with some degree ofaloneness.20A differentsource de fi ned resilience as an individual's notfeeling alone while going through a hard time in life,accepting the situation,being able to go for his/her own choice among limited choices,and seeing this as an opportunity to get better chances,being hopeful,spiritual,optimistic and faithful, making sense ofhis/her life,and having meaningfulrelationships.11

Another source de fi ned resilience as selfhood,flexibility,faith, self-con fi dence and creativity,empathic and humanistic approach, and developed insight about responsibilities and roles,good physical health to contribute to mental wellness,good social network,and hobbies.6Another characteristic of resilience is an inner energy or life power to help an individualto persist.9

It is possible to conclude the following on resilience after reviewing de fi nitions given the above:resilience could be de fi ned in different ways for different environments with some of its constant characteristics,in such a way that it is possible to de fi ne resilience in disease,natural disaster,war,education,business life and daily life.No matter whatwe de fi ne as a dif fi cult circumstance, what matters is that the sick or resilient individual's effort to recover or adapt,notto lose his/her faith and hope,to be able to use social support resources in that dif fi cult circumstance,to have spiritual values and an aim in life.Thus,it is possible to discuss resilience.

3.Signi fi cance of resilience for nursing

Stress is a major concern in the nursing profession.Common stressors are work overload,role con flicts,experiences of aggression,lack of time,staf fi ng issues,shift work,lack of self-care,poor job-related interpersonal relationships,feeling powerless to provide quality care,struggling with competing demands,ensuring excellentpatientcare,uncertainty concerning treatment,death and dying,con flict with doctors,peers and supervisors and inadequate emotional preparation.21e25Nursing people with HIV/AIDS, vulnerable children and people who are terminally ill,and working in emergencies and oncology services might be depressive for nurses.25e29

These depressive factors cause both physical and mental problems,such as fatigue,irritability,lack of concentration,unhappiness,depressive sensation,depersonalization and emotional exhaustion.23,28Negative stress-related causes not only have an impacton nurses'wellness butalso theircaregiving to patients.30In this respect,it is possible to say that resilience is a protective agent with nurses'physical and mental wellbeing.Manzano-Garcia& Ayala-Calvo's study5on 983 nurses revealed that resilience is an important protective factor against emotional exhaustion. Furthermore,a source de fi nes resilience as a supportive factor that helps nurses to adapt to their profession's dif fi cult physical,mental and emotional nature.31

Factors such as balance in business life,hope,control,professional identity and clinical supervision contribute to nurses'resilience.30In another study,it was emphasized that resilience levelof nurses was associated with characteristics such as hope,selfef fi cacy,control,coping and competence.32The same study stated that age,experience,education leveland years ofwork do not have a contributive in fluence on resilience.

There are other studies in the literature that investigated the relation of resilience to factors such as job satisfaction,33emotional exhaustion,5post-traumatic stress disorder3and burnout.34Based on the outcomes of these studies it is possible to say that positive social relationships,optimism,spirituality and having a resilient role-model has a positive impact on nurses'resilience level,while nurses with low resilience level experience more emotional exhaustion and job dissatisfaction.

It is also possible to de fi ne resilience as a protective factor besides being an individual characteristic that helps nurses struggle with their professionaldif fi culties.Fig.1 shows the levels ofnurses' resilience,such as coping,optimism,self-ef fi cacy,sense of humor, control,competence,hope and spirituality,which means that if a nurse holds abovementioned characteristics,she/he is resilient. These characteristics might contribute to dealwith their depressive factors more ef fi ciently,use their problem solving skills,not lose their control on events and adapt to depressive factors.

4.Research on improving nurse resilience

McDonald et al.35performed an educational intervention to improve nurses'and midwives'resilience,which came to the conclusion that their self-con fi dence,self-mindfulness,communication and problem solving skills were improved.Additionally,the same research revealed that educated nurses and midwives strengthen their relationships with their colleagues.McDonald et al.36applied a work-based educational intervention to nurses and midwives working in very busy clinics and aimed at helping them to maintain their resilience level.As a result,the attendants improved their self-con fi dence,self-awareness,boldness,and selfcare.

Craigie et al.37applied a resilience intervention program to nurses in order to improve their emotionalwell-being and to lower their mercy exhaustion.They reported signi fi cant improvements in their mercy exhaustion,exhaustion,and stress levels.Maunder et al.38conducted a computer-based resilience training in order to prepare medical staff for in fluenza pandemia,which contributed positively to improve their self-con fi dence,self-ef fi cacy,their coping methods and interpersonalproblems.

Gerhart et al.39conducted an awareness based communication training in order to improve resilience of medical staff and found that cognitive fusion,depression symptoms,depersonalizations and post-traumatic stress fi ndings decreased.Foureur et al.40approached the issue with a different point with the aim to improve resilience of nurses and midwives.The aim of this study was to improve their health and sense of coherence,while decreasing the levelofdepression,anxiety,and stress levels.At the end of the study,their health and sense of coherence increased, while their stress leveldecreased.

A different study integrated Stress Management and Resiliency Training(SMART)program into the usual orientation program, which is conducted for new nurses,nurses who switched to a different service,or nurses who have a new role in the establishment.41At the end of this study,it was found that the SMARTprogram was an effective program to improve resilience of nurses. Mealer et al.42conducted a 12-week training program for intensive care nurses.After the program,it was observed that there was a signi fi cant decrease in post-traumatic stress disorder levels of nurses.

Fig.1.The characteristics of a resilient nurse.

5.Attempts to increase resilience

We have indicated that resilience can be learned and improved, providing examples from various applications.In this respect, mentorship programs are suggested in order to improve resilience. Mentorship programs might contribute to resilience by improving positive and supportive professional relationships,by supporting optimism,emotionalinsight,life balance and spirituality.30

McDonald et al.35had developed an intervention modelaiming to facilitate positive responses to nurses'workplace environment through the exploration ofpracticaland relevant coping strategies. This intervention model consisted of fi ve workshop including mentoring relationships,establishing positive nurturing relationships and networks,building hardiness,maintaining a positive outlook,intellectual flexibility,emotional intelligence,achieving life balance,enabling spirituality,and re flective and critical thinking.McDonald et al.36also suggested to create the opportunities for an experimental learning,creative self-expression and new ideas and strategies,to increase assertiveness at work and collaborative capital,to improve workplace relationships and communication,and to understand self-care practices.

An intervention model can be created to develop resilience in nursing professionals through the recommendations of McAllister &McKinnon.43This intervention model can be consisted of de fi ning and strengthening the predictors of resilience,giving opportunities to re flect upon and to learn from practice and from other practitioners,and improving professional cultural generativity.The predictors of resilience are cognitive ability,adaptability,positive identity,social support,coping skills,spiritual connection,ability to fi nd meaning in adversity.The professional cultural generativity,demonstrated by altruism,setting a good sample,mentoring,leading,coaching and motivating others should be encouraged in those entering nursing profession.

Zander et al.43investigated resilience in pediatric oncology nurses and gave some suggestions according to their fi ndings. These suggestions revealed the components of the intervention program including an orientation program,clinical supervision,a supportive environment and advanced insight.An orientation program and clinical supervision were based on sharing fi rst nursing experiences related to cope with the dif fi culties at work, recognizing different strategies such as emotional management and expression,talking,and problem solving.Additionally,through dealing with situations,using support,knowing and managing themselves,as well as accepting and acknowledging lessons and facts relating to working their clinics,insight can be developed.

Another strategy to improve resilience is to de fi ne protective factors for nurses,as well as improve key skills in order to protect themselves against problems in the work environment.2These skills will help to balance the negative emotions,obtain positive aspects of their experience,and gain positive coping strategies. Within the process of establishing resilience of nurses it is also of high importance to build supportive relationships as well as socialsupport,having an optimistic and positive point ofview,having the emotional insight necessary to be aware of their own emotional needs,having a balance in their lives,having spiritual beliefs and self-criticism or self-evaluation.

Cameron&Brownie31proposed that these attempts are important in order to improve resilience of nurses:(1)Having knowledge and skills in time management,crisis intervention, specifying the priorities;(2)Improving work satisfaction;(3) Having a positive attitude,making a difference or having a sense of faith;(4)Building among nurses the belieffor making a difference, building close and warm relationships,and preparing environments for them to share their experiences;(5)Using strategies such as debrie fi ng,validation and self-re flection;(6)Getting support from colleagues,mentors and team fellows;(7)Improving the skill for sense of humor in order to know depressive agents and their negative effects;(8)Offering options such as exercise,rest,social support and interests that are ef fi cient to build a balance and maintain that balance between career life and daily life.

McAllister and McKinnon44discussed three recommendations to develop resilience in health professionals.The fi rst of these recommendations is that predictors of resilience,such as during undergraduate education cognitive ability,adaptability,positive identity,socialsupport,coping skills,spiritualconnection,ability to fi nd meaning in adversity,can be strengthened and learned by educational activities.Another recommendation is to give opportunities to re flect upon and learn from practice and from other practitioners.The third recommendation is that professional cultural generativity,demonstrated by altruism,setting a good example,mentoring,leading,coaching and motivating others should be encouraged in those entering health professions.

Edward,6in his study with six mental health professionals working in crisis intervention,found that resilience is a product of autonomy,responsibility and con fi dence,and a result of using creativity,flexibility,and humor in the work environment and that it could be improved by having belief and ethics.Therefore,autonomy,responsibility,and con fi dence need to be developed in order to improve resilience of nurses.A supportive environment needs to be established,their awareness of beliefs and ethics need to be increased and they need to be taught about tips for creativity and humor in career life.

Environment is an important factor to improve resilience.It is highly important to build a potentially stress-free work environment.45It has been mentioned above that this environment needs to have supportive relationships as well.Among environmental agents are positive role-models in this environment,scheduling shifts,and increasing job satisfaction.3,31,43,45There could be a quiet or serenity room within the work environment where nurses could have a rest,relax,pray,meditate,or apply some self-care applications to get away from a busy day's stress.9

Interventions to build or improve resilience ofnurses are shown in Table 1.As they are reviewed,it is seen that they are categorized in 3 as improving individual characters,organizing the work environment,and increasing socialsupportsources.Itis possible to prepare,to equip and to strengthen nurses for problems they encounter such that both physical and mental problems could be eliminated.

6.Conclusions

The International Nurses'Day theme for 2016 of International Councilof Nurses(ICN)is“Nurses:A Force for Change:Improving Health Systems'Resilience.”If we strive to improve health establishments and care given to patients,we also need to improve nurses because nurses have important knowledge and skills tobuild and maintain changes.The way to increase and secure this power is to improve the resilience of nurses.

Table 1 Interventions to build or improve resilience of nurses.

Conflicts of interest

There is no con flicts of interest.

1.McAllister M,Lowe JB.Preparing for practice:becoming resilient.In: McAllister M,Lowe JB,eds.The Resilient Nurse:Empowering Your Practice.New York:Springer Publishing Company;2011:1e22.

2.Jackson D,Firtko A,Edenborough M.Personal resilience as a strategy for surviving and thriving in the face of workplace adversity:a literature review.JAdv Nurs.2007;60:1e9.

3.Mealer M,Jones J,Moss M.A qualitative study of resilience and posttraumatic stress disorder in United States ICU nurses.Intensive Care Med.2012;38: 1445e1451.

4.Earvolino-Ramirez M.Resilience:a concept analysis.Nurs Forum.2007;42: 73e82.

5.Manzano G,Ayala-Calvo JC.Emotional exhaustion of nursing staff:in fluence of emotional annoyance and resilience.Int Nurs Rev.2012;59:101e107.

6.Edward KL.The phenomenon of resilience in crisis care mental health clinicians.Int J Ment Health Nurs.2005;14:142e148.

7.Sameroff AJ,Rosenblum KL.Psychosocial constraints on the development of resilience.Ann N Y Acad Sci.2006;1094:116e124.

8.Ahern NR.Adolescent resilience:an evolutionary concept analysis.J Pediatr Nurs.2006;21:175e185.

9.Grafton E,Gillespie B,Henderson S.Resilience:the power within.Oncol Nurs Forum.2010;37:698e705.

10.Felten BS.Resilience in a multicultural sample of community-dwelling women older than age 85.Clin Nurse Res.2000;9:102e123.

11.Edward KL,Welch A,Chater K.The phenomenon of resilience as described by adults who have experienced mental illness.J Adv Nurs.2009;65:587e595.

12.Ungar M.Resilience across cultures.Br J Soc Work.2008;38:218e235.

13.Masten AS,Obradovic J.Competence and resilience in development.Ann N Y Acad Sci.2006;1094:13e27.

14.€Oz F,Bahad?r-Y?lmaz E.A signi fi cant concept in protecting mental health: resilience.Sagl?k Bilimleri Dergisi.2009;16:82e89(in Turkish).

15.Tusaie K,Dyer J.Resilience:a historical review of the construct.Holist Nurs Pract.2004;18:3e8.

16.Cleary M,Jackson D,Hungerford CL.Mental health nursing in Australia: resilience as a means of sustaining the specialty.Issues Ment Health Nurs. 2014;35:33e40.

17.Bahad?r-Y?lmaz E.Resilience levels of junior nursing and midwifery students according to their stress coping styles.Hems?irelik Fakültesi Dergisi.2015;31: 52e61(in Turkish).

18.Wu LM,Sheen JM,Shu HL,Chang SC,Hsiao CC.Predictors of anxiety and resilience in adolescents undergoing cancer treatment.J Adv Nurs.2013;69: 158e166.

19.Fadardi JS,Azad H,Nematy A.The relationship between resilience,motivational structure,and substance use.Proced Soc Behav Sci.2010;5:1956e1960.

20.Smith PR.Resilience:resistance factor for depressive symptom.JPsychiatr Ment Health Nurs.2009;16:829e837.

21.Lim J,Bogossian F,Ahern K.Stress and coping in Australian nurses:a systematic review.Int Nurs Rev.2010;57:22e31.

22.Gulavani A,Shinde MB.Occupational stress and job satisfaction among nurses. Int J Sci Res.2014;3:733e740.

23.Matsuzaki K,Uemura H,Yasui T.Associations of menopausal symptoms with job-related stress factors in nurses in Japan.Maturitas.2014;79:77e85.

24.Enns CL,Sawatzky JA.Emergency nurses'perspectives:factors affecting caring. J Emerg Nurs.2016;42:240e245.

25.De Almeida Vicente A,Shadvar S,Lepage S,Rennick JE.Experienced pediatric nurses'perceptions of work-related stressors on general medical and surgical units:a qualitative study.Int J Nurs Stud.2016;60:216e224.

26.Duffy E,Avalos G,Dowling M.Secondary traumatic stress among emergency nurses:a cross-sectional study.Int Emerg Nurs.2015;23:53e58.

27.Dong F,Zheng R,Chen X,Wang Y,Zhou H,Sun R.Caring for dying cancer patients in the Chinese cultural context:a qualitative study from the perspectives of physicians and nurses.Eur J Oncol Nurs.2016;21:189e196.

28.Makhado L,Davhana-Maselesele M.Knowledge and psychosocial wellbeing of nurses caring for people living with HIV/AIDS(PLWH).Health Sa Gesonheid. 2016;21:1e10.

29.Yu H,Jiang A,Shen J.Prevalence and predictors of compassion fatigue,burnout and compassion satisfaction among oncology nurses:a cross-sectional survey. Int J Nurs Stud.2016;57:28e38.

30.McCann CM,Beddoe E,McCormick K,et al.Resilience in the health professions: a review of recent literature.Int J Wellbeing.2013;3:60e81.

31.Cameron F,Brownie S.Enhancing resilience in registered aged care nurses. Australas JAgeing.2010;29:66e71.

32.Gillespie BM,Chaboyer W,Wallis M,Grimbeek P.Resilience in the operating room:developing and testing of a resilience model.J Adv Nur.2007;59: 427e438.

33.Matos PS,Neushotz LA,Grif fi n MT,Fitzpatrick JJ.An exploratory study of resilience and job satisfaction among psychiatric nurses working in inpatient units.Int J Ment Health Nurs.2010;19:307e312.

34.Rushton CH,Batcheller J,Schroeder K,Donohue P.Burnout and resilience among nurses practicing in high-intensity settings.Am J Crit Care.2015;24: 412e420.

35.McDonald G,Jackson D,Wilkes L,Vickers MH.A work-based educational intervention to support the development of personal resilience in nurses and midwives.Nurse Educ Today.2012;32:378e384.

36.McDonald G,Jackson D,Wilkes L,Vickers MH.Personalresilience in nurses and midwives:effects of a work-based educational intervention.Contempy Nurse. 2013;45:134e143.

37.Craigie M,Slatyer S,Hegney D,et al.A pilot evaluation of a mindful self-care and resiliency(MSCR)intervention for nurses.Mindfulness.2016;7:764e774.

38.Maunder RG,Lancee WJ,Mae R,et al.Computer-assisted resilience training to prepare healthcare workers for pandemic in fluenza:a randomized trial of the optimal dose of training.BMC Health Serv Res.2010;10:72.

39.Gerhart J,O'Mahony S,Abrams I,Grosse J,Greene MM,Levy M.A pilot test of mindfulness-based communication training to enhance resilience in palliative care professionals.J Contextual Behav Sci.2016;5:89e96.

40.Foureur M,Besley K,Burton G,Yu N,Crisp J.Enhancing the resilience of nurses and midwives:pilot of a mindfulness-based program for increased health, sense of coherence and decreased depression,anxiety and stress.Contemp Nurse.2013;45:114e125.

41.Chesak SS,Bhagra A,Schroeder DR,Foy DA,Cutshall SM,Sood A.Enhancing resilience among new nurses:feasibility and ef fi cacy of a pilot intervention. Ochsner J.2015;15:38e44.

42.Mealer M,Conrad D,Evans J,et al.Feasibility and acceptability of a resilience training program for intensive care unit nurses.Am J Crit Care.2014;23: 97e105.

43.Zander M,Hutton A,King L.Exploring resilience in paediatric oncology nursing staff.Collegian.2013;20:17e25.

44.McAllister M,McKinnon J.The importance of teaching and learning resilience in the health disciplines:a critical review of the literature.Nurse Educ Today. 2009;29:371e379.

45.Warelow P,Edward KL.Caring as a resilient practice in mental health nursing. Int J Ment Health Nurs.2007;16:132e135.

How to cite this article:Y?lmaz EB.Resilience as a strategy for struggling against challenges related to the nursing profession. Chin Nurs Res. 2017;4:9e13. http://dx.doi.org/10.1016/ j.cnre.2017.03.004

21 July 2016

E-mail address:ebahadiryilmaz@yahoo.com.

Peer review under responsibility of Shanxi Medical Periodical Press.

http://dx.doi.org/10.1016/j.cnre.2017.03.004

2095-7718/?2017 Shanxi MedicalPeriodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons. org/licenses/by-nc-nd/4.0/).

Received in revised form 15 October 2016

Accepted 7 January 2017

Available online 30 March 2017