Nurse Education Today 36 (2016) 457–462

Contents lists available at ScienceDirect

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
Lawrence Memorial Regis College Nursing Program, 170 Governors Avenue, Medford MA 02155, United States
b
Doctoral Student University of Massachusetts Dartmouth, United States
c
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 s u m m a r y

Article history: Objective: The aim of this integrative review was to investigate the state of knowledge on resilience in nursing
Accepted 15 October 2015 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.
Keywords: Design: Integrative literature review.
Resilience
Data Sources: Cumulative Index to Nursing and Allied Health (CINHAL), Education Resources Information Center
Nursing students
(ERIC) and PsychINFO electronic databases were searched for publications between 1990 and 2014. Search terms
Nursing education
Pre licensure
included resilience, student, nurse, nursing student, hardiness, emotional resilience, research, resili*, and nurse*.
Integrative review 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 empower-
ment. 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 in-
cludes how one learns to grow stronger from the experience
(McAllister and McKinnon, 2009). Understanding resilience in nurs-
ing 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, nurs-
ing students are exposed to many firsts in the clinical arena, includ-
ing 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: lthomas@lmh.edu (L.J. Thomas), susan.hunterrevell@umassd.edu
(S.H. Revell).
1
Tel.: +1 781 696 9318; fax: +1 978 261 5640.
2
Tel.: +1 508 999 8507.
the formation of nurses (Benner, Sutphen, Leonard, and Day, 2010).
Becoming a nurse is more than being socialized into the role. The pro-
tective factors identified in the concept of resilience include having op-
timism, a sense of humor, flexibility, and self-efficacy. It is believed that
enhancing resilience through these factors, directly relates to the forma-
tion 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 out-
comes 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 en-
vironment. Researchers identified protective factors that people with

http://dx.doi.org/10.1016/j.nedt.2015.10.016
0260-6917/© 2015 Elsevier Ltd. All rights reserved.
458 L.J. Thomas, S.H. Revell / Nurse Education Today 36 (2016) 457–462
resilience possess such as, positive outlook, self-esteem, problem solv-
ing 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 pa-
rental 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 de-
scribed 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 resilience-
training 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 mea-
surements 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 in-
vestigated nurses as role models and sources of support to develop resil-
ience in patients with HIV/AIDS (Dyer, Patsdaughter, McGuinness,
O'Connnor, and Desantis, 2004). It was found that nurses who are resil-
ient, 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 out-
comes in a study by Bradshaw et al. (2007). Researchers conducted a
multidisciplinary interventional study in patients with type two diabe-
tes. The experimental group received resilience education while the
control group received standard treatment. Members of the interven-
tion group had significant increases in exercise, dietary control and psy-
chosocial 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 phenom-
enon within the discipline of nursing. Nurses are intimately involved
with suffering and tragedy on a daily basis and are instrumental in help-
ing 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 resil-
ience 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 re-
flection (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, posi-
tive emotions and personal growth and professional reflection
(Jackson et al., 2007). Based on this review an educational interven-
tion 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 in-
creased assertiveness, supportive communication, closer staff dy-
namic, and an understanding of self-care as it relates to resilience
(McDonald et al., 2013).
Researchers have made clear recommendations to incorporate resil-
ience 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 litera-
ture 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) integra-
tive review method consists of five stages: problem identification, liter-
ature 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. Psy-
chometric 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 de-
tails). Ancestry searches of retrieved articles were done to enhance
Table 1
Search terms.
Concept Subject headings Text words
Resilience Resilience, nursing student, Resilience, resilie*
emotional resilience Emotional resilience
Nurse*, nursing student,
nurse and student
Hardiness Hardiness, nursing student Hardiness
Nurse*, nursing student,
nurse and student
Years of publication 1990–2014.
 L.J. Thomas, S.H. Revell / Nurse Education Today 36 (2016) 457–462
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 dupli-
cates, which resulted in 45 articles. The abstracts of these articles were
evaluated based on the following inclusion criteria: (a) described resil-
ience in nursing students, (b) measured resilience in pre-licensure nurs-
ing 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 work-
place 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 phe-
nomenological. Evaluation is more complex when there is greater diver-
sity 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
Fig. 1. Data collection process.
459
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 rela-
tion 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 integra-
tion 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 re-
searchers did not offer a specific definition (see Table 3). When compar-
ing 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 def-
inition of resilience in adolescents, which includes risk as its antecedent.
Character traits described by researchers in the discipline of psychol-
ogy 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 state-
ment “resilience is the ability to bounce back” is a consequence identi-
fied 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 persever-
ance and the integration of the experience into oneself was used in one
study (Hodges, Keeley and Grier, 2005). Carroll (2011) is the only re-
searcher that specifies academic success as an outcome of resilience.
Stephens (2013) conducted a concept analysis of nursing student re-
silience. 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 specif-
ically addresses resilience in nursing students.
Factors Affecting Resilience in Nursing Students
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 phenome-
nological 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
460 L.J. Thomas, S.H. Revell / Nurse Education Today 36 (2016) 457–462

Table 2
Matrix of literature reviewed.

Author year/country Methodology Setting/sample Strategies/findings Quality 1 = high

2 = low

Pines et al. (2014) US
Pitt et al. (2014) AU
Crombie et al. (2013) UK
Stephens (2013) US
Stephens (2012) US
Taylor et al. (2012) US
Pines et al. (2012) US
Carroll (2011) US
Hodges et al. (2005)
Pilot interventional study
Descriptive longitudinal
Ethnographic case study
Concept clarification (Norris
method)
Interventional repeated measures
during a twitter intervention
Pretest posttest
quasi-experimental design
Correlational
Phenomenological
Theoretical
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
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
166 generic BSN Jr and Sr level.
South West US
11 undergrad students near
graduation
California
Focus on Parse's HBST
• Four training modules over two semesters. 1
• 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 1
year gap
• Older students were found to have higher
levels of resilience
• Fostering resilience 2
• Peer group support in clinical and class
• Family as support structure
• Operational definition 1
• Nursing student model
• Hypothesis
• Experimental group had increased resil- 1
ience post but not at follow up
• Two subsets of the RS perseverance and ex- 2
istential aloneness had sig increases from
beginning of semester to end,
• No difference in RS across the curriculum
• Significant moderate correlation of RS be-
tween grades on the 1st and last exam
• Resilience and empowerment were posi- 1
tively correlated
• Themes found: support, perseverance, 1
autonomy, empathy, high expectations,
sense of purpose, optimism, honesty, critical
thinking
• Coaching role for faculty 1
• Reflection, connection, resilience
• Professional identity related to resilience

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 con-
ducted with students in their second year of a London based univer-
sity found that resilience influenced rates of program completion
(Crombie et al., 2013).
Furthermore Carroll (2011) and Crombie et al. (2013) found that en-
couragement 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 inter-
views 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 ex-
plored 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
to their ability to reach within themselves to succeed (Taylor and
Reyes, 2012). In contrast Stephens (2012) believed that cumulative suc-
cess 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 re-
searchers 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 recommenda-
tions 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 sepa-
rately 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 re-
silient 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 stu-
dents 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) 457–462 461

Table 3 pretest, posttest and follow-up design. The participants were junior
Definitions and descriptions of resilience across the literature. level baccalaureate student's aged 19–23. Students in the experimental
Author Definition/description group received four educational messages or questions (tweets) each
Hodges, Keeley and Grier (2005) “Resilience consists of suffering and
week that were intended to promote resilience. Students in the control
perseverance, working through emerging group got four tweets with nursing trivia or basic nursing information.
difficulties and integrating crisis experiences Like the Pines et al. study the intervention was “loosely” based on the
into one's sense of well being” (p. 550) “Reaching Out and Reaching In” curriculum. A different theme was
Pines, Rauschhuber, Cook, Norgan, “Resilience is the ability of an individual to
highlighted each week. The themes included: social support, positive
Canchola, Rischardson and adjust to adversity, maintain equilibrium,
Jones (2014) retain some control over the environment and emotions, humor, knowledge of health behaviors, self-knowledge and
move in a positive direction.” (p. 86) effective coping. Questions included: What is your greatest strength?
Pines et al. (2012) “Resilience is the ability to bounce back. The How does this help you? Who is the most positive influence in your
personal attributes of resilient people include life? What can you learn from him/her? If a student tweeted, other stu-
an internal locus of control, pro-social
behavior, empathy, positive self image,
dents could respond and have dialog but the researcher did not. Resil-
optimism and the ability to organize daily ience scores initially increased between pretest and posttest, but then
responsibilities.” (p. 1483) declined at follow up (Stephens, 2012).
Carroll (2011) “Resiliency refers to the construct that the The pilot study done by Pines et al. (2014) does not provide detailed
nursing student way be equipped with internal
information regarding the educational sessions that were administered
qualities and/or be supported by external
forces that promote academic success in spite to students. This makes the comparison to the Stephens' (2013) study
of stressful circumstances. (p. 13) difficult. Stephens' (2013) research is a dissertation therefore great de-
Stephens (2012) Ahern's definition of adolescent resilience is tail about the intervention was provided. The theoretical information
used for theoretical and conceptual developed by Hodges et al. (2005) is very interesting but has not been
congruence. Adolescent resilience as a “process
tested. This variation is a limitation to the integration of strategies to en-
of adaptation to risk that incorporates personal
characteristics, family and social support, and hance resilience in nursing students. More work in both theoretical and
community resources” (p. 3). interventional specific to nursing students needs to be done in the area
Stephens (2013) “Nursing student resilience is an individualized of resilience.
process of development that occurs through
the use of personal protective factors to
successfully navigate perceived stress and
adversities. Cumulative success lead to Discussion
enhanced coping/adaptive abilities and
well-being.” (p. 130) The concept of resilience in nursing students is in its infancy. With
Taylor and Reyes (2012) “Resilience in individuals has been defined as
the exception of one theoretical article that was written in 2005, the re-
the ability to rise above difficult situations;
adapt better than expected in the face of maining work has been published within the last three years. Stephens
significant adversity; and recover from difficulty (2013) constructed a definition and model through her concept analysis
and overcome adverse circumstances in one's but thus far it has not been utilized or tested. It was hoped that through
life”. (p. 2)
this review more description of resilience in nursing students would be
evident, however that is not yet clear in the literature. This is a limita-
tion. A well-tested definition would allow for clarity in the measure-
(2005) propose that reflection should be developed early in conjunction ment of resilience. The use of a consistent definition can aid in the
with other basic nursing skills. “Resilience can develop from intentional comparison of studies thus making the science stronger. This is a critical
reflection, step by cumulative step” (Hodges et al., 2005, p.553). The act point in the literature that has not been well established. It would be
of writing allows a student a time away from the noise and busyness of beneficial to further examine factors that contribute to resilience in
practice to think and construct thoughts about nursing. Through the re- nursing students through qualitative research. Data gathered would
flection, instructors have a window into what a student is experiencing either support Stephens' (2013) definition or further refine it. There
and can navigate and support the student to build resilience (Hodges are multiple studies that correlate resilience in relation to other vari-
et al., 2005). ables, academic success, self-efficacy and empowerment but no studies
A pilot study was conducted to evaluate the use of a resilience inter- provide an answer to the question; what variables impact resilience in
vention with nursing students based on the “Reaching Out and Reaching nursing students? A quantitative descriptive study to answer this ques-
In” curriculum. (Pines et al., 2014). This program has been successful in tion would further define the concept of resilience as it relates to nurs-
young children, adolescents and college students (Pines et al., 2014). ing students.
The curriculum was adapted specifically for nursing students and topics Research has identified resilience as important for nurses which led
included: principles of resiliency and behaviors of resilient nurses, pro- to the notion of enhancing resilience in nursing students to better pre-
fessional empowerment strategies in the workplace, conflict manage- pare them for their professional role (Hodges, Troyan and Keeley,
ment styles and teamwork training. Four modules were presented 2010; Jackson et al., 2007; McAllister and McKinnon, 2009; Pines et al.,
over two semesters consisting of class followed by simulation and 2012; Stephens, 2013). The two interventional studies reviewed uti-
debriefing. The purpose of the pilot was to evaluate whether nursing lized social media (Stephens, 2012) and classroom educational modules
students who participated in resilience education would have increased (Pines et al., 2014). Stephens' (2012) Twitter intervention initially dem-
resiliency scores at the end of the program. Resilience was measured onstrated an increase in resilience at posttest, however when evaluated
with the Stress Resiliency Profile (SRP), empowerment and conflict again one-month post the resilience scores had decreased. Pines et al.
management were also measured. There were no significant changes (2014) set of four modules over two semesters did not result in an in-
in resilience scores from pretest to posttest (Pines et al., 2014). This crease in resilience measures. It could be said that the frequent short in-
demonstrates the complexity required to enhance resilience in nursing terventions in Stephens' (2012) study are more beneficial than more
students. sporadic interventions over two semesters in the Pines' et al. (2014)
Stephens (2012) conducted a study using twitter to deliver an edu- study. A direction for further research may include short doses of inter-
cational intervention to enhance resilience in nursing students. This ventions over a longer period of time to assess effectiveness. The time of
multisite study consisted of an experimental and control group, with re- delivery during a nursing program is also a consideration. Research that
silience measured by The Connor-Davidson Resilience Scale using a evaluates the effectiveness of enhancing resilience at various points of
462 L.J. Thomas, S.H. Revell / Nurse Education Today 36 (2016) 457–462
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 demon-
strated reflection as a strategy to reduce anxiety in students and facili-
tate 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 be-
ginning 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 ex-
ploring 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 re-
search topic, there is sufficient information in the literature to inform
faculty how to promote resilience. Nurse educators are in a unique po-
sition 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 ac-
cess 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 stu-
dents 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 resil-
ient nurses.
Nurse faculty are responsible to prepare students to be profes-
sional 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 chal-
lenged 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 need-
ed. 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 pre-
pare them for longevity in today's healthcare system.
References
Benner, P., Sutphen, M., Leonard, V., Day, L., 2010. Educating Nurses: A Call for Radical
Transformation. Jossey-Bass, San Francisco: San Francisco.
Bradshaw, B.G., Richardson, G.E., Kumpfer, K., Carlson, J., Stanchfield, J., Overall, J., Brooks,
A., Kulkarni, K., 2007. Determining the efficacy of a resiliency training approach in
adults with type 2 diabetes. Diabetes Educ. 33 (4), 650 report.
Carroll, S., 2011. Resiliency as a Factor in the Successful Completion of a California Com-
munity College Based Associate Degree in Nursing Program (Unpublished Doctoral
Dissertation). California Lutheran University, California.
Cooper, H., 1998. Synthesizing Research: A Guide for Literature Reviews. 3rd. ed Sage
Publications, Thousand Oaks, CA.
Crombie, A., Brindley, J., Harris, D., Marks-Maran, D., Thompson, T.M., 2013. Factors that
enhance rates of completion: what makes students stay? Nurse Educ. Today 33
(11), 1282–1287. http://dx.doi.org/10.1016/j.nedt.2013.03.020.
Davies, E., 1995. Reflective practice: a focus for caring. J. Nurs. Educ. 34 (4), 167–174.
Dyer, J.G., Patsdaughter, C.A., McGuinness, T.M., O'Connor, C., DeSantis, J.P., 2004. Retro-
spective resilience: the power of the patient–provider alliance in disenfranchised
persons with HIV/AIDS. J. Multicult. Nurs.Health 10 (1), 57–65.
Edwards, D., Burnard, P., Bennett, K., Hebden, U., 2010. A longitudinal study of stress and
self-esteem in student nurses. Nurse Educ. Today 30 (1), 78–84. http://dx.doi.org/10.
1016/j.nedt.2009.06.008.
Garmezy, N., Masten, A.S., Tellegen, A., 1984. The study of stress and competence in chil-
dren: a building block for developmental psychopathology. Child Dev. 55, 97–111.
http://dx.doi.org/10.1080/13548506.2011.564189.
Gillespie, B.M., Chaboyer, W., Wallis, M., 2007. Development of a theoretically derived
model of resilience through concept analysis. Contemp. Nurse. J. Aust. Nurs. Profes-
sion 25 (1-2), 124–135. http://dx.doi.org/10.5172/conu.2007.25.1-2.124.
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.1547-
5069.2009.01325.x.
Jackson, D., Firtko, A., Edenborough, M., 2007. Personal resilience as a strategy for surviv-
ing 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 man-
agement 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 develop-
ment 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. Determining the efficacy of resiliency training in the
work site. J. Allied Health 33 (3), 178.
Whittemore, R., Knafl, K., 2005. The integrative review: updated methodology. J. Adv.
Nurs. 52 (5), 546–553. http://dx.doi.org/10.1111/j.1365-2648.2005.03621.x.