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International Journal of Mental Health Nursing (2019) 28, 71–85 doi: 10.1111/inm.12548

R EVIEW A RTICLE
Resilience and mental health nursing: An
integrative review of international literature
Kim Foster,1,2 Michael Roche,1,3 Cynthia Delgado,1,4,5 Celeste Cuzzillo,1,2
Jo-Ann Giandinoto1,2 and Trentham Furness1,2
1
School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, 2NorthWestern Mental
Health, Melbourne Health, Parkville, Victoria, Australia, 3Northern Sydney Local Health District Mental Health
Drug and Alcohol Services, Sydney, 4Susan Wakil School of Nursing and Midwifery, Sydney Nursing School,
Faculty of Medicine and Health, University of Sydney, and 5Sydney Local Health District Mental Health Services,
Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, New
South Wales, Australia

ABSTRACT: Mental health nurses work in challenging and potentially high stress settings.
Stressors can occur in the context of consumer, family, and/or staff relationships, as well as the
work environment and organization. The cumulative effects of stress and professional challenges
can lead to harmful impacts for mental health nurses including burnout and poorer physical and
mental health. Resilience involves a process of positive adaptation to stress and adversity. The
aims of this integrative review were to examine understandings and perspectives on resilience, and
explore and synthesize the state of knowledge on resilience in mental health nursing. Following
systematic search processes, screening, and data extraction, 12 articles were included. Constant
comparative analysis and synthesis of the data resulted in two key categories: Theoretical concepts
of resilience and Knowledge on mental health nurses’ resilience. In mental health nursing,
resilience has been variously constructed as an individual ability, collective capacity, or as an
interactive person–environment process. Resilience was most often reported as low-moderate, with
positive correlations with hardiness, self-esteem, life and job satisfaction, and negative correlations
with depression and burnout. A resilience programme improved mental health nurses’ coping self-
efficacy and capacity to regulate thoughts and emotions and developed their resilient practice. Use
of contemporary resilience definitions will inform more consistent investigation and progressively
scaffold knowledge of this emergent construct in mental health nursing. Future research on the
implementation of resilience programmes and resilience-building strategies for mental health
nurses at the individual, work unit, and organizational levels is needed.
KEY WORDS: mental health nursing, resilience, resilient practice, stressors, well-being.

Correspondence: Professor Kim Foster, Mental Health Nursing Research Unit, Australian Catholic University and NorthWestern Mental
Health, The Royal Melbourne Hospital, Grattan Street, Parkville, Vic., Australia 3050. Email: kim.foster@acu.edu.au
Authorship Statement: KF, CC, and TF contributed to the conception and/or design of the study. All authors collected and/or analysed data.
All authors contributed to the construction of the manuscript and approved the final version.
Conflict of interest: Nothing to disclose.
Kim Foster, RN, PhD.
Michael Roche, PhD.
Cynthia Delgado, RN, MN (MH-NP).
Celeste Cuzzillo, GradDipPsych.
Jo-Ann Giandinoto, RN, BN (Hons).
Trentham Furness, PhD.
Accepted September 06 2018.

© 2018 Australian College of Mental Health Nurses Inc.

72
INTRODUCTION
Mental health services provide specialist care for
people with a range of mental illnesses (Australian
Institute of Health and Welfare 2018), and nurses
are the largest discipline group in the mental health
workforce (Australian Institute of Health and Welfare
2018). Mental health nurses possess unique clinical
and interpersonal skills for working with people with
mental illness (Delaney et al. 2018), yet can be chal-
lenged to practice effectively in the context of work-
place stressors (Roche et al. 2011; R€ ossler 2012). For
mental health nurses (MHN hereafter), workplace
stress can lead to burnout (Morse et al. 2012),
poorer mental health and physical health (Kelly et al.
2016), and reduced well-being (Edward et al. 2017).
Despite these known concerns, there has been rela-
tively little attention in the literature to promoting
MHN health and well-being (Morse et al. 2012).
Resilience can be understood as a process of positive
adaptation to stress and adversity, involving dynamic
interactions between personal and environmental fac-
tors and resources (King & Rothstein 2010). To date,
there has been no systematic review of the evidence
on resilience in mental health nursing. This paper
reports an integrative review of resilience in the spe-
cialty field of mental health nursing for the purpose
of building the knowledge base and to inform future
enquiry and intervention in this field.
BACKGROUND
Mental health nurses face substantial stressors and
professional challenges in the workplace. These can
occur in relation to consumers and families, other
staff, as well as the work unit and/or organization.
Mental health nurses report high levels of consumer-
related verbal and/or physical aggression (Jalil et al.
2017; Tonso et al. 2016), and substantial emotional
labour in performing their roles (Edward et al. 2017).
They may be involved in the use of coercive prac-
tices (e.g. physical restraint and seclusion) which can
be experienced as traumatic (Muir-Cochrane et al.
2018) and lead to feelings of fear and guilt (Jalil
et al. 2017; Muir-Cochrane et al. 2018). Interpersonal
conflicts with colleagues, including bullying, can
result in psychological distress (Tonso et al. 2016). At
the organizational level, high acuity (Tonso et al.
2016), substantial workload (Yanchus et al. 2017), and
insufficient resources (McTiernan & McDonald 2015)
are reported.
K. FOSTER ET AL.
The cumulative effects of stressors and professional
challenges for mental health nurses can lead to harmful
impacts including long-term stress (Lanct^ot & Guay
2014), emotional dissonance and burnout (Edward
et al. 2017), and other mental health concerns such as
post-traumatic stress disorder (PTSD; Jacobowitz 2013)
and depression (Wang et al. 2015). Nurses’ workplace
stress has been associated with job dissatisfaction
(Baum & Kagan 2015) and can negatively impact work-
place retention (Lamont et al. 2017) and the quality of
nursing practice (Roche et al. 2011). As such, there is
an imperative to identify proactive strategies to reduce
the negative outcomes of workplace stress for mental
health nurses.
As a dynamic process of positive adaptation to
adversity such as workplace stress, resilience involves
the capacity of a system (e.g. an individual) to ‘adapt
successfully to disturbances that threaten system func-
tion, viability, or development’ (Masten 2014, pp. 6).
There are various forms of resilience. Psychological
resilience involves the use of a range of meta-cognitive
and emotional processes in protecting people from the
negative effects of stress (Fletcher & Sarkar 2013). Psy-
chological resilience has been widely investigated for
more than four decades in several ‘waves’ of enquiry.
The initial focus was on protective factors and personal
characteristics that helped individuals adapt to risk.
Further enquiry identified resilience processes and
environmental factors influencing people’s capacity to
adapt. Later enquiry involved development of resili-
ence-building interventions and investigation of resili-
ence in the context of the workplace (Fletcher &
Sarkar 2013; Vanhove et al. 2016).
In the wider field of nursing, evidence reviews
report that resilience has been investigated most com-
monly as an individual psychological construct, with
conceptualizations ranging from resilience as an ability
or group of personal characteristics, through to resili-
ence as a process that occurs between people and their
environment (Delgado et al. 2017). Personal character-
istics such as hope, coping, and self-efficacy have been
found to promote nurses’ resilience (Hart et al. 2014).
As Traynor (2017) recognizes, however, resilience
involves vital interactive processes between nurses and
their workplace environment. As a process, resilience
can be protective against the harmful impacts of the
emotional labour of nursing work (Delgado et al.
2017). In nursing and midwifery, effective resilience-
building strategies include work–life balance, cognitive
reframing, a strong sense of professional identity,
accessing support, and positive connections with others
© 2018 Australian College of Mental Health Nurses Inc.
RESILIENCE AND MENTAL HEALTH NURSING 73

(Hart et al. 2014; Hunter & Warren 2014). In the TABLE 1: Search terms
wider field of nursing, resilience has been associated Content area† Subject heading† Search Terms†
with lower levels of PTSD and burnout and higher
Nursing Psychiatric nursing Psychiatric nurs*
levels of psychological health (Mealer et al. 2012a,b),
Mental health nurse Mental health nurs*
improved collegial relationships (McDonald et al. Resilience Adaptation, psychological resilien*
2013), and greater professional quality of life (Hegney Coping adapt*
et al. 2015). There has been no prior review of litera- Psychological well-being coping
ture, however, of the knowledge on resilience in the Resilience, psychological withstand*
specialty field of mental health nursing. Emotional adjustment adjust*
Hardiness resist*
wellbeing
Aims well-being
overcome*
The aims of the review were to explore and synthesize psycholog*
the state of knowledge on resilience in mental health behav*
respon*
nursing and to examine understandings and perspectives
emotion*
on resilience in mental health nursing. The questions
†
that guided the review were as follows: (i) What are the Boolean methods AND with OR were used.
understandings and perspectives on resilience in the
mental health nursing literature? And (ii) what is the majority of the sample population for inclusion. Articles
state of Knowledge on mental health nurses’ resilience? on undergraduate education and student nurses, editori-
als, non-peer-reviewed articles, literature reviews, dis-
sertations, book chapters, conference proceedings, and
METHODS
other grey literature were excluded.
An integrative review method was undertaken to
address the study aims. This method was employed as
Screening
it involves systematic searching of the literature and
allows for inclusion of both empirical and theoretical Titles and abstracts of 1236 papers were independently
literature, with the goal of providing a comprehensive screened for relevance by three authors against the inclu-
synthesis of the existing knowledge base (Whittemore sion and exclusion criteria. The initial screening of abstracts
& Knafl 2005). A systematic search process was and titles was conducted using Rayyan QCRI, a web appli-
employed to locate relevant literature. The process cation facilitating the independent review of articles for
involved searching key databases using predetermined inclusion (Ouzzani et al. 2016). Full text of retained articles
search terms related to the topic (see Table 1). Rele- was read and screened, and after consensus discussion, a
vant articles were selected, and data were extracted total of 12 articles were included for review (see Fig. 1).
and then analysed and synthesized.
Analysis and quality assessment
Data sources
Consistent with the Whittemore and Knafl (2005)
MEDLINE Complete, CINAHL Complete, and Psy- method, a data extraction tool was developed according
cINFO databases were searched for titles and abstracts to the review questions and relevant data from included
(see Table 1). Reference lists of key articles were papers were extracted for analysis. Key concepts and
hand-searched to locate any abstracts not identified emergent patterns in the data were identified using con-
through electronic database searching. stant comparative analysis. This method allows for sys-
tematic interpretations of the data and categories to be
developed (Whittemore & Knafl 2005). The data extrac-
Inclusion and exclusion criteria
tion tool in the form of a matrix facilitated this process.
Peer-reviewed empirical research, theoretical, or discus- Data were extracted from each article by the authors
sion papers on resilience in relation to mental health and coded for the review questions. Codes were com-
nursing, published in English language between January pared and contrasted in an iterative process within and
2000 and June 2018, were included. For empirical across articles, and key concepts were collated. Emer-
papers, mental health nurses needed to comprise the gent categories and subcategories were then identified

© 2018 Australian College of Mental Health Nurses Inc.

74 K. FOSTER ET AL.

and discussed by the team until consensus was reached.
The data were synthesized into an integrated summary
of findings in major and subcategories.
Whittemore and Knafl (2005) recommend that
papers are assessed for methodological quality. The
quality of the empirical papers (n = 9) was assessed
using the Mixed Methods Appraisal Tool (MMAT).
This tool, with established validity and reliability, was
appropriate as it has criteria that allow for the assess-
ment of a range of research designs (Pluye et al. 2011).
Two authors independently appraised articles against
the criteria for the methodology and four quality crite-
ria on the MMAT. The scores were represented by (*)
meeting one criterion to (****) meeting all criteria.
Where there was a score discrepancy, consensus was
reached through discussion. The articles were generally
of sound methodological quality. All studies met at
least two of the criteria, and no study was excluded.
The discussion papers (n = 3) were assessed for quality
by two authors using the Joanna Briggs Institute six
item, Narrative, Opinion, Text Assessment and Review
Instrument (NOTARI; McArthur et al. 2015). This tool
allows for the appraisal of text and opinion papers.
Included articles were evaluated in respect to the
established expertise of the author(s), articulated argu-
ment, and recommendations made (McArthur et al.
2015). Any inconsistencies in assessment were dis-
cussed by the authors until mutual agreement was
reached. Quality scores are in Table 2.
RESULTS
Description of the articles
The review included 12 articles: nine were empirical
and three were discussion/theoretical (see Table 2 for

Records identified through database

searching
(n = 1773)
Identification

Records after duplicates (n=537) removed

(n = 1236)
Screening

Records screened Records excluded

(n = 1236) (n = 1227)

Articles identified through title and Additional records identified through

abstract screening (n = 9) hand searching (n = 3)
Eligibility

Full-text articles assessed

for eligibility
(n = 12)
Included

Studies included
(n = 12)

FIG. 1: PRISMA flow chart of search and screening process (Moher et al. 2009). [Colour figure can be viewed at wileyonlinelibrary.com]

© 2018 Australian College of Mental Health Nurses Inc.

RESILIENCE AND MENTAL HEALTH NURSING
summary of included articles). Half (n = 6) the articles
were from Australia, with the rest from Japan, Singa-
pore, USA, Canada, Palestine, and Israel. Four Aus-
tralian authors had written more than one article (i.e.
Edward and Warelow, and Foster and Furness). The
majority (n = 11) focused solely on mental health
nurses. One study included perspectives of mental
health care clinicians; most (4/6) of who were mental
health nurses (Edward 2005). Two key categories with
related subcategories derived from analysis were: Theo-
retical concepts of resilience and Knowledge on mental
health nurses’ resilience.
Theoretical concepts of resilience
Articles were reviewed for theoretical conceptualiza-
tions of resilience. Most authors drew on literature from
a range of fields, including nursing (Cleary et al. 2014;
Matos et al. 2010; Prosser et al. 2017), psychology
(Edward 2005), organizational theory (Cleary et al.
2014), and allied and public health (Cleary et al. 2014)
to represent their understandings of resilience. In most
articles, multiple definitions of resilience were cited,
with authors acknowledging that it was a complex and
multidimensional construct. Cleary et al. (2014), for
instance, discussed at length the diverse conceptualiza-
tions of resilience and argued that resilience can be con-
sidered within the context in which it is to be applied,
for example the workplace. Warelow and Edward
(2007), citing early theories of resilience (Garmezy
1991), and those from the wider nursing literature
(Tusaie & Dyer 2004), identified that resilience involved
a relationship between intrapersonal and environmental
factors. Itzhaki et al. (2015) and Prosser et al. (2017)
acknowledged that resilience was not consistently
defined in the literature and that conceptually it ranged
from an individual quality and trait to a process.
Resilience was co-associated with other key con-
structs in the included articles. Most often, it was
associated with emotional intelligence (n = 4/12;
Cleary et al. 2014; Edward & Warelow 2005; Foster
et al. 2018a; Warelow & Edward 2007), which was
considered an aspect of (Foster et al. 2018a), or over-
lapping construct with (Warelow & Edward 2007),
resilience. Further, resilience was associated (Foster
et al. 2018a), or correlated with, post-traumatic growth
(Itzhaki et al. 2015). The following distinct concepts of
resilience were identified across articles; resilience as
primarily an individual ability or characteristic, as an
interactive person–environment process, and as a col-
lective capacity.
© 2018 Australian College of Mental Health Nurses Inc.
75
Resilience as primarily an individual ability or
characteristic
Resilience was referred to in six articles primarily as an
individual ability, trait, or characteristic (Edward 2005;
Edward & Warelow 2005; Gito et al. 2013; Matos et al.
2010; Prosser et al. 2017; Zheng et al. 2017). Some
authors minimally and/or unclearly defined resilience
(Warelow & Edward 2007; Zheng et al. 2017), although
both articles referred to individual abilities. Several
authors (n = 5/12 articles) drew on earlier understand-
ings of resilience as an individual characteristic as
defined by key researchers in psychology and psychia-
try (Caplan 1990; Curtis & Cicchetti 2003; Rutter
1985). Here, resilience was considered a personal
resource within the individual and through repeated
exposure to difficult situations (e.g. stress, trauma, or
other adversity, for example workplace violence) the
individual could develop adaptive behaviours.
Resilience was described as an individual trait and
ability to bounce back from adversity (Edward 2005), a
personal resource that allows for individuals to positively
adjust to adversity (Gito et al. 2013), and as an individ-
ual’s capacity to problem solve and cognitively appraise
adverse situations through which self-mastery and adap-
tive behaviours are learned (Zheng et al. 2017). Matos
et al. (2010) identified resilience as a means for nurses
to adapt to stress in the workplace but acknowledged
that the concept is complex. Prosser et al. (2017) con-
cluded that regardless of definition, developing resili-
ence was within the ability of individual nurses and
could, therefore, be developed with targeted strategies.
Resilience as an interactive person–environment process
More recent articles (n = 3/12) offered resilience con-
ceptualizations which extended the notion of resilience
as being internal to the individual. Foster et al. (2018a,
b) and Marie et al. (2017) provided social–ecological
definitions of resilience. These definitions were based
on resilience theory defined by Ungar (2008, 2011).
The social–ecological definition of resilience empha-
sizes individuals’ capacity to find resources that sustain
their well-being, and the ability of their environment,
including family, community, and the workplace, to
provide resources in ways that are culturally meaning-
ful (Ungar 2008). Consistent with this definition, Marie
et al. (2017) in their study in Palestine highlighted the
importance of understanding resilience as being
embedded within specific cultural contexts. They illus-
trated this through use of the socio-political concept of
‘Sumud’ (steadfastness) as an ecological source of resili-
ence for mental health nurses in Palestine. Foster et al.
 TABLE 2: Summary of included papers

Author(s) (Year) Participants and Data collection 76

Country Paper type/design Aims/purpose setting methods Results/Conclusions Limitations Quality rating

Cleary et al. (2014) Discussion Considers notion N/A N/A Collective/group resilience N/A NOTARI 100%
Australia (Draws on of resilience from may apply to sustain the
Delphi study perspective of strength of MHN specialty
findings to MHN specialty, as the profession will
discuss and ways MHN continue to endure changes
resilience) has adapted to
changes
Edward (2005) Qualitative, Explore the 6 mental health In-depth focused, 4 themes: Small sample size MMAT***
Australia Phenomenology phenomenon of crisis care individual (i) Sense of Self Combined MHN
resilience for workers interviews lasting (ii) Faith & Hope and other crisis
crisis care including between 30 and (iii) Having Insight care health
clinicians MHNs (n = 4) 60 min (iv) Looking after Yourself workers
Edward and Discussion No aim or N/A N/A Increasing MHN N/A NOTARI 100%
Warelow (2005) purpose understanding of resilience
Australia identified and EI may have the
potential to improve clinical
outcomes for mental health
consumers
Foster et al. (2018b) Quantitative, Describe 24 MHNs, high- (i) Depression, High fidelity and user Small sample MMAT****
Australia Pretest, post-test feasibility of acuity settings in Anxiety & Stress satisfaction from one service
with 3 month PAR, a workplace a mental health Scale (DASS-21) Significant improvement in Some loss to
follow-up resilience service (ii) Satisfaction Coping Self-efficacy and follow-up at third
programme, with with Life Scale decrease in anxiety and time point
MHNs (iii) Ryff’s Scale stress symptoms (n = 8/24)
of Psychological Clinically significant
Well-Being improvement in cognitive
(iv) Satisfaction subscales of WRI,
with work suggesting that MHN
(v) Coping self- improved in controlling
efficacy scale negative and ineffective
(vi) Workplace thoughts and behaviours
Resilience
Inventory (WRI)
(vii) Program
Fidelity Checklist
& Participant
Satisfaction
Survey

(Continued)

© 2018 Australian College of Mental Health Nurses Inc.

K. FOSTER ET AL.
 TABLE 2: (Continued)

Author(s) (Year) Participants and Data collection

Country Paper type/design Aims/purpose setting methods Results/Conclusions Limitations Quality rating

Foster et al. (2018) Qualitative, Explore 29 MHNs, large Interviews and Nurses with higher levels of Highly skilled MMAT****
Australia Inductive experiences and metropolitan focus groups and resilience had less clinicians from
exploratory perspectives of public mental open-ended depression and burnout. one service
MHNs who health service in survey responses Nurses with higher levels of Findings may not
participated in Australia resilience had higher levels be transferable to
PAR resilience of hardiness. other settings
programme Nurses with higher levels of
resilience experienced less
depression and burnout
Gito et al. (2013) Quantitative, Examine 327 nurses at 3 (i) Resilience Although mental health Did not define MMAT***
Japan Cross-sectional resilience of psychiatric Scale for Nurses nurses are frequently resilience
survey, nurses in hospitals in rural (RSN) exposed to violence, their Key terms not
correlational psychiatric Japan (ii) Japanese Self- life satisfaction is affected defined
hospitals in Esteem Scale more by resilience, PTG, Sample located
Japan. Two (iii) Japanese and job stress than by in rural Japan
RESILIENCE AND MENTAL HEALTH NURSING

hypotheses: 1) Hardiness Scale workplace violence

© 2018 Australian College of Mental Health Nurses Inc.

resilience is 20
negatively (iv) Japanese
correlated to version Beck
depression and Depression
burnout; Inventory
2) resilience is (v) Japanese
positively version Burnout
correlated to Scale
hardiness and
self-esteem
Itzhaki et al. (2015) Quantitative, Explore effects of 118 MHNs, one Self-report, 4 themes: Sample from one MMAT***
Israel Descriptive exposure to mental health structured (i) Sumud & Islamic mental health
cross-sectional violence, job hospital questionnaire Culture hospital in Israel
survey stress, staff designed for the (ii) Supportive relationships Cross-sectional
resilience, and study (iii) Making use of Available design used to
PTG on life Resources measure PTG
satisfaction of (iv) Personal Capacity Other potential
MHN variables such as
fatigue and
compassion not
measured

(Continued)
77
 TABLE 2: (Continued)

Author(s) (Year) Participants and Data collection 78

Country Paper type/design Aims/purpose setting methods Results/Conclusions Limitations Quality rating

Marie et al. (2017) Qualitative, Observe and 15 CMHNs, two 32-hour High level of resilience and Only Palestinian MMAT****
Palestine Interpretive describe the community observations of high job satisfaction. nurses in West
qualitative design environment, mental health day-to-day Job satisfaction subscale of Bank area
challenges and centres working professional status had One time point
sources of environment and highest mean rating.
resilience for workplace Physician–nurse interaction
community routines. subscale had lowest mean
MHNs Analysis of score
multiple policy
documents.
15 face-to-face
in-depth
interviews.
Matos et al. (2010) Quantitative, Examine 32 RNs, five (i) Resilience 4 themes: Small sample MMAT**
USA Descriptive, relationship inpatient units in Scale (i)Maintaining a ‘vast’ size, single site,
correlational between large urban (ii) Index of perspective cross-sectional
resilience and job academic medical Work Satisfaction (ii) Becoming an ‘expert’ of
satisfaction in centre Part B scale self
psychiatric nurses (iii) Clarifying ‘belief
systems’
(iv) Being ‘present’ through
‘staying awake
Prosser et al. (2017) Qualitative, Understand how 4 nurses from Single semi- Caring should include EI Small sample MMAT****
Canada IPA registered nurses acute psychiatric structured face- and resilience. EI, size, limited to
in acute units in regional to-face interviews resilience and resilient one hospital
psychiatric Alberta 60–90 min behaviours have potential to
settings develop assist person to transcend
resilience to negative experiences and
sustain practice transform them into positive
ones
Warelow and Edward (2007) Discussion Discuss caring as N/A N/A Positive association between Resilience not NOTARI 83%
Australia modern MHN resilience and job clearly defined
satisfaction (b = 0.109,
P = 0.003)
Positive association between
higher age and years’
experience and resilience
(P < 0.01)

(Continued)

© 2018 Australian College of Mental Health Nurses Inc.

K. FOSTER ET AL.
RESILIENCE AND MENTAL HEALTH NURSING 79

CMHN, community mental health nurse; EI, emotional intelligence; IPA, interpretive phenomenological analysis; MHN, mental health nurse; MMAT, Mixed Methods Appraisal Tool;
(2018a) applied social–ecological theory to outline a
Quality rating model for strategies to strengthen MHN workplace
MMAT****

NOTARI, Narrative, Opinion, Text Assessment and Review Instrument; PAR, Promoting Adult Resilience programme; PTG, post-traumatic growth; USA, United States of America.
resilience at individual, work unit, organizational, and
professional levels.

Resilience as a collective capacity

In a further conceptual advance, in addition to under-
design. Sample
Cross-sectional
Limitations

from one site

standing resilience as an individual construct several

authors acknowledged resilience to be a group or col-
lective capacity (Cleary et al. 2014; Foster et al. 2018a;
Itzhaki et al. 2015). Cleary et al. (2014) defined this as
‘the capacity of the profession to withstand adversity
Positive association between

Positive association between

experience and resilience

and continue to develop positively in the face of

Results/Conclusions

satisfaction (b = 0.109,

higher age and years’

change’ (p. 33). This ‘professional’ or ‘group’ resilience

resilience and job

was considered context-specific, with mental health

nurses viewed as a ‘resilient group’ due to being able
P = 0.003).

(P < 0.01)

to survive and grow within the context of multiple pro-

fessional changes over time. As a group, the profession
could, therefore, be ‘greater than the sum of its parts’
(Cleary et al. 2014, p. 37).
demographic data
Satisfaction Scale
(i) McCloskey &
Data collection

(ii) Resilience
Mueller’s Job
methods

Knowledge on mental health nurses’ resilience

(iii) Socio-

There were four qualitative studies that explored MHN

Scale

experiences of resilience and five quantitative studies

that measured MHN resilience and associated factors.
Participants and

nurses from only

In addition, the discussion papers considered resilience

726 psychiatric

institution in
setting

from professional and environmental perspectives and

psychiatric

Singapore

proposed further associations and applications. The

tertiary

majority of articles acknowledged limited research with

MHN had been undertaken. In respect to the wider
field of nursing, most authors (Cleary et al. 2014; Fos-
resilience and job

associated socio-
Explore level of
Aims/purpose

satisfaction and

ter et al. 2018a,b; Itzhaki et al. 2015; Matos et al. 2010;

among MHNs,
job satisfaction

relationship of

demographic
the possible

Zheng et al. 2017) noted that while resilience of nurses

in other specialties such as perioperative, intensive
factors

care, emergency, and palliative care had been increas-

ingly studied, in comparison, investigation of MHN
resilience was negligible.
Paper type/design

Cross-sectional
Quantitative,

Experience of MHN Resilience

The experience of resilience was described using phe-
survey

nomenological and interpretive qualitative approaches.

A total of 52 MHN across 4 studies described experi-
ences of resilience in community (n = 15; Marie et al.
TABLE 2: (Continued)

2017), crisis care (n = 4; Edward 2005), and acute

inpatient (n = 33; Foster et al. 2018a; Prosser et al.
Zheng et al. (2017)

2017) mental health settings. Studies identified themes

Author(s) (Year)

of resilience as an individual self-concept and a system

Singapore

of belief, and nurses applying resilience skills in their

Country

work, which involved the need for self-care, support

from others, training, and other resources.

© 2018 Australian College of Mental Health Nurses Inc.

80
Resilience was found to be an individual self-con-
cept by several authors; that is, resilient nurses were
experts of self and possessed a range of personal char-
acteristics including tenacity and creativity. Prosser
et al. (2017) found MHN becoming ‘experts of self’,
which involved a strong understanding of their per-
sonal experience, skills, knowledge, strengths, and lim-
itations. Other personal characteristics such as
tenacity, flexibility, and creativity were identified
(Edward 2005; Marie et al. 2017), along with MHN
being able to identify the need to reflect and to locate
external supports. Mental health nurses’ systems of
belief were resilience resources that could enable
them to reframe adverse situations in work and life
into those that were meaningful (Prosser et al. 2017),
and helped them develop plans to achieve their goals
(Marie et al. 2017). Belief systems that sustained
MHN included cultural (Marie et al. 2017) and spiri-
tual beliefs and/or a sense of faith (Edward 2005;
Prosser et al. 2017). A love of nursing and strong
belief systems (Marie et al. 2017) involved nurses’
capacity to ‘make sense’ of challenging situations
through placing them in a context or structure and to
identify a given situation or action in terms of making
a potentially positive contribution.
Resilience was a quality which could be ‘nurtured’
or ‘developed’. Self-care was linked to a strong individ-
ual concept of resilience, where knowledge-of-self pro-
vided opportunity for activities that supported resilient
MHN behaviours (Edward 2005). This included funda-
mentals such as appropriate diet, sleep, exercise, and
having a strong social network, alongside resilience pro-
grammes (Marie et al. 2017). The support of the nurs-
ing and multidisciplinary team is a logical extension of
self-care although it may also be considered an organi-
zational resource (Cleary et al. 2014; Foster et al.
2018a). The notion of ‘resilient practice’ was identified
in two studies (Foster et al. 2018a; Warelow & Edward
2007). This was initially identified by Warelow and
Edward (2007) in relation to MHN caring practices,
where they contended resilience could be a practice
and strategy cultivated through education and role
modelling. Foster et al. (2018a) extended understand-
ings of MHN resilient practice in finding that through
resilience education MHN improved their ability to
control negative and ineffective thoughts, manage
stress, and emotionally self-regulate. This enabled
nurses to respond successfully in challenging interac-
tions and to practice more effectively with consumers
in complex interpersonal situations such as conflict or
violence.
K. FOSTER ET AL.
Measurement of MHN Resilience
The level of resilience has been measured for a total of
1237 MHN across 5 studies, 4 of which used cross-sec-
tional survey designs. Resilience was quantified using
the 10-item shortened Connor-Davidson Resilience
Scale (CD-RISC-10; Campbell-Sills & Stein 2007), the
25-item Resilience Scale (Wagnild & Young 1993), and
the Workplace Resilience Inventory (WRI; McLarnon
& Rothstein 2013). Itzhaki et al. (2015) assessed the
resilience of MHN from a group perspective (i.e. the
resilience of an entire group (n = 118)) and found that
it was low, in the 25th percentile (CD-RISC-
10 = 2.88). Two studies described MHN resilience as a
personality characteristic, assessing it as moderately low
(Resilience Scale = 127.99, n = 726; Zheng et al. 2017)
and moderate (Resilience Scale = 145, n = 32; Matos
et al. 2010). Foster et al. (2018b) described MHN resi-
lience with the WRI which is a process-based measure
of workplace resilience. Their findings were that three
months following a resilience intervention MHN
reported a strong level of workplace resilience
(WRI = 2.5–4.2, n = 24). Gito et al. (2013) used the
32-item Resilience Scale for Nurses (RSN; Ihara et al.
2010) to describe the individual resilience of 327
MHN, but did not report the RSN values.
Factors associated with MHN resilience
Regardless of the overall level of resilience, a higher
level of MHN resilience has been associated with a
range of individual or group factors and outcomes.
Although most are in the low-to-moderate range, posi-
tive correlations have been identified between resilience
and hardiness (r = 0.27), self-esteem (r = 0.38; Gito
et al. 2013), coping self-efficacy (r = 0.80; Foster et al.
2018b), life satisfaction (r = 0.19; Itzhaki et al. 2015),
and job satisfaction (r = 0.81; Foster et al. 2018b;
r = 0.33; Matos et al. 2010; b = 0.11; Zheng et al.
2017). Resilience has been negatively correlated with
depression (r = 0.61; Foster et al. 2018b; r = 0.26;
Gito et al. 2013), anxiety (r = 0.58; Foster et al.
2018b), stress (r = 0.84; Foster et al. 2018b), and
burnout (r = 0.31; Gito et al. 2013). Further, Itzhaki
et al. (2015) found that life satisfaction of MHN was
linked to group resilience (b = 0.18), post-traumatic
growth (b = 0.40), and general job stress (b = 0.22),
but not to workplace violence (b = 0.15).
In addition to individual growth, authors also pro-
posed that resilient behaviours may foster a positive
work environment for all MHN, with potential impacts
on nurse, system, and consumer outcomes. This is con-
sistent with the concept of group or collective
© 2018 Australian College of Mental Health Nurses Inc.
RESILIENCE AND MENTAL HEALTH NURSING
resilience of the profession as defined by Cleary et al.
(2014). Organizational factors play a key role in profes-
sional resilience which may reinforce and strengthen
MHN resilience. Studies identified the environment
was an important influence on MHN life (Itzhaki et al.
2015) and job satisfaction (Matos et al. 2010).
DISCUSSION
In this review, we explored the existing knowledge and
understandings of resilience in mental health nursing.
While resilience has been investigated increasingly in
the wider field of nursing, emergent literature in MHN
in the last 5 years indicates a growing recognition and
interest in the relevance of resilience for this specialty
field. The review found a range of theoretical under-
standings and conceptualizations of resilience were
used, including earlier concepts of resilience. MHN
resilience was subsequently explored and measured dif-
ferently across studies. In some cases, resilience was
not clearly defined, which was a particular issue when
the construct was subsequently measured. The problem
with lack of conceptual clarity with a commonly used
construct is that investigation of the construct is incon-
sistent and knowledge is not scaffolded and extended.
It is recommended that future MHN research draw on
contemporary conceptualizations of resilience from the
wider literature, based on evolving theory and research
from leading resilience researchers (see for e.g. South-
wick et al. 2014).
In this review, most articles were from English-
speaking countries. It is recognized by leaders in the
field that resilience has been defined predominantly as
a Western construct, with research focusing on out-
comes that emphasize individual and interpersonal fac-
tors and which may not be sensitive to cultural factors
that influence how resilience is defined and understood
(Ungar 2008). Further research is needed that explores
MHN resilience across cultures, and the cultural and
environmental factors that may influence understand-
ings and expressions of their resilience, as illustrated in
the study by Marie et al. (2017).
There was a prevailing focus in the reviewed litera-
ture on personal resilience, with measurement of resili-
ence primarily as a trait-based or individual attribute.
Focusing on resilience as existing within the individual
alone can be seen to place the responsibility for posi-
tive adaptation on the individual. There is potential to
judge or blame the person if they do not respond posi-
tively following adversity. Contemporary understand-
ings of resilience are that it is a dynamic process of
© 2018 Australian College of Mental Health Nurses Inc.
81
interaction between the individual and their environ-
ment (Masten 2014). It is recommended that future
research with MHN use process-based measures, for
example the Workplace Resilience Inventory (McLar-
non & Rothstein 2013), that include individual and
environmental factors.
A further finding was the emergent association
between nurses’ resilience and their practice (e.g. Fos-
ter et al. 2018a; Warelow & Edward 2007), indicating
that nurses apply personal resilience strategies to their
practice and this can improve their relationships with
colleagues and consumers and strengthen their capacity
to provide effective healthcare. Resilience may be one
of the central capacities required to develop effective
therapeutic relationships, alongside mental health nurs-
ing experience, knowledge, and clinical skills. In health
research, there are emergent links being made between
resilience and patient safety and the quality of practice
—for example ‘resilient healthcare’ (Braithwaite et al.
2015). These are important areas for further investiga-
tion in mental health nursing.
The current literature on MHN resilience suggests
that managers and colleagues in a unit or team can
influence staff well-being and satisfaction at work
(Cleary et al. 2014; Edward 2005). This is an area for
further investigation as the existing literature has
focused primarily on individual MHN resilience rather
than environmental factors influencing their resilience.
There is a lack of empirical research investigating the
efficacy of recommendations for building MHN resili-
ence. Only one study has reported on the impacts of
resilience programmes for MHN (Foster et al. 2018a,
b). Further implementation and investigation of resili-
ence programmes and other recommended resilience
strategies and resources with larger samples and in
controlled trials are needed to establish their efficacy.
CONCLUSION AND RELEVANCE FOR
CLINICAL PRACTICE
This review has synthesized the existing knowledge on
resilience in mental health nursing. The findings from
the review demonstrate that mental health nurses are
able to strengthen their resilience through a range of
strategies. Authors in the reviewed papers consistently
identified that it was the responsibility of employers and
organizations to provide strategies to sustain MHN resi-
lience. Managers and organizations are accountable for
developing and maintaining staff resilience through pro-
viding professional development opportunities and
proactive approaches to ensure a safe, secure, and
 TABLE 3: Recommendations for strengthening MHN resilience

Individual Work unit 82

EI strategies Build positive Clinical leadership
Peer support Focus on (e.g. empathy Resilience Self-care/awareness/ team culture/stigma Professional and managerial
Author (year) network strengths Optimism building) education spirituality reduction development support

Cleary et al. (2014) U U U - U U U U U

Edward (2005)
Edward and
Warelow (2005)
Foster et al. (2018a)
Foster et al. (2018b)
Gito et al. (2013)
Itzhaki et al. (2015)
Marie et al. (2017)
Matos et al. (2010)
Prosser et al. (2017)
Warelow and
Edward (2007)
Zheng et al. (2017)
- -
- -
U U
- -
- -
U -
U U
- -
- U
- -
U -
- -
- U
U U
- -
- -
U U
U U
- -
- -
- U
- -
U U U - U
U - - - -
U U U U U
U - - U U
- - - - -
U U U U U
U U U U U
- - U - -
- U - - -
U - - - U
- - U U -

Organizational Professional
Safety initiatives Well-being Undergraduate
Culture of (incl. aggression Resilience- informed Providing Collective and stress education
supporting management clinical supervision/reflective Recruitment/ resilience education professional reduction resilience
Author (year) staff well-being training) practice Retention strategies programmes (e.g. PAR) identity support modules

Cleary et al. (2014) U - - U U U U -

Edward (2005)
Edward and
Warelow (2005)
Foster et al. (2018a)
Foster et al. (2018b)
Gito et al. (2013)
Itzhaki et al. (2015)
Marie et al. (2017)
Matos et al. (2010)
Prosser et al. (2017)
Warelow and
Edward (2007)
Zheng et al. (2017)
- - - U U - - U
- - - - U - U -
U U U - U U U -
U - - - U - - -
- - - - - - - -
U U - - U U U -
- - - - U U U U
- - - - U - - -
- - - - U - - -
- - - - U - U -
U - - - U - U -

EI, Emotional Intelligence; PAR, Promoting Adult Resilience.

© 2018 Australian College of Mental Health Nurses Inc.

K. FOSTER ET AL.
RESILIENCE AND MENTAL HEALTH NURSING
flexible work environment (Cleary et al. (2014). Find-
ings from this review indicate that MHN personal resili-
ence overall is low-moderate. A multifaceted approach
to building and maintaining their resilience is needed.
All authors except Gito et al. (2013) made recommenda-
tions for strengthening MHN resilience. Using a social–
ecological framework, these recommendations have
been synthesized by the authors according to individual,
work unit, organizational, and professional levels (see
Table 3). We recommend these individual, work unit,
and organizational strategies are implemented and
tested, ideally in combination, in a range of mental
health contexts and across roles and levels of seniority to
support and strengthen nurses’ resilience and practice.
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