Nursing is a knowledge- and technical-based profession that requires lifelong learning. Nursing continuing education is essential in providing nurses with updated nursing knowledge and skills to achieve safe and quality patient care (American Nurses Association, 2015; Harper & Maloney, 2017). Hospitals' continuing education and training make significant differences in nurses' performance at work, including increased self-confidence, nursing knowledge, critical thinking, and interpersonal skills (Abdul Rahman, Jarrar, & Don, 2015). Continuing professional development has been positively correlated with staff satisfaction, retention, and patient care quality (Levett-Jones, 2005). With the growing body of literature emphasizing the relationships between nurse burnout and resilience and patient care quality, the nurse leaders at a teaching hospital wanted to evaluate nurses' resilience and their perceived job-related stressors to provide appropriate training programs in the hospital.
Resilience is an evolving concept. According to the concept analyses and a review of the literature, resilience has been described in various ways, such as an ability, characteristic, skill, or process to adapt (Kester & Wei, 2018; Yilmaz, 2017). Connor and Davidson (2003) described resilience as the personal qualities that help individuals thrive when facing adversity and developed the Connor-Davidson Resilience Scale. Since its conception, this scale has been used worldwide. It comprises five factors that are related to: (1) personal competence and tenacity, (2) belief in one's instincts and the tolerance of adversities, (3) positive acceptance of situations and change, (4) feelings of being in control, and (5) spiritual influences. Resilience is considered an effective way to reduce stress and burnout (Kester & Wei, 2018; Yilmaz, 2017).
Helping nurses build resilience is a vital approach to maintain a stable nurse workforce and provide a high quality of patient care. As the major workforce in health care, nurses face an increased risk of work-related stress, which makes building nurse resilience a pressing priority for the Future of Nursing 2020–2030 (National Academy of Medicine, 2019). Continuing education is considered an integral part of nurses' professional development (Shinners, 2019).
Although nurse resilience building has progressed in the United States, it is in the initial stage in China, where the focus of continuing education is still on nurses' clinical skills. There is a pressing need to understand nurse resilience and influencing factors to determine the best strategies for promoting nurse resilience. Therefore, the aim of this study was to examine the current state and influencing factors of nurses' resilience and perceived job-related stressors, and identify strategies to promote resilience.
This study was approved by the ethics committee of the Hospital Research Management Department. Participation in the study was anonymous and voluntary.
This was a cross-sectional survey study. This design would provide information about the current state and influencing factors of clinical nurses' resilience. The knowledge gained could be used as a basis for designing continuing education programs in the hospital.
Setting and Sample
This study was conducted in a university-affiliated hospital on the east coast of China between May and August 2018. The hospital has a total of 5000 beds and employs 3392 full-time nurses. The sample was a convenience sample of full-time RNs employed at the hospital. The inclusion criteria were clinical nurses who provided direct patient care and full-time RNs who were either permanent or contract-based. Nurses who did not provide direct patient care, such as nurses working in administrative positions, were excluded.
Demographic Questionnaire. A demographic survey was designed by the study research team. This questionnaire gathered information on nurses' age, gender, marital status, work unit, work experience, education, and clinical rank. The clinical ranks were classified into four levels: level I staff nurses, level II senior nurses, level III nurses-in-charge, and level IV deputy chief nurses.
Psychological Resilience. Nurse resilience was measured using the 25-item Chinese version of the Connor-Davidson Resilience Scale (CD-RISC) (Connor & Davidson, 2003; Yu & Zhang, 2007). The original 25-item CD-RISC was developed by Connor and Davidson (2003). The reliability coefficient of the Chinese version of the scale is 0.91 (Yu & Zhang, 2007). The 25 items were assessed using a 4-point scale (0 = not at all, 1 = seldom true, 2 = sometimes true, 3 = often true, and 4 = extremely true). The total possible score for the resilience scale is 100 points. Higher scores indicate a higher level of resilience. The Cronbach alpha coefficient for this study was .937. An average of the total resilience scores was calculated as recommended by Connor and Davidson (2003). Permission to use the CD-RISC 25 was obtained from the author of the scale (Dr. Davidson).
Questionnaire of Nurse-Perceived Stressors. The data on nurse-perceived stressors and ways to promote resilience were collected using a questionnaire developed by the authors based on the situations of the hospital. Nurses were asked to write their concerns or perceptions of stressors affecting their job performance and their physical and psychological health. Nurses also were asked to list ways that nurse leaders could help them alleviate stressors and build resilience.
Data were collected using two platforms: Questionnaire Star™ and WeChat. Questionnaire Star™ is a professional online questionnaire platform. WeChat is a Chinese multipurpose messaging and social media platform. An invitation to participate in the study was e-mailed to all of the nurses employed in the hospital through WeChat. Upon opening the link embedded in the invitation, nurses were introduced to the study and asked to complete the consent form. After consenting to participate in the study, nurses were provided with a link to answer the questionnaire, which was anonymous and administered through Questionnaire Star™. A reminder e-mail was sent to the nurses to encourage their participation.
Data analysis was performed using IBM® SPSS® version 25 statistical software. Data were analyzed using the descriptive statistical analysis, t/F test, one-way analysis of variance, and multiple linear regression analysis. A p value less than .05 was considered statistically significant.
Of 3,392 nurses invited, a total of 2,981 nurses participated in the study for a participation rate of 88%. The majority of the participants were female (n = 2,816; 94.50%) and younger than age 36 years (n = 2,488; 83.46%). Nearly three quarters (n = 2,189; 73.40%) of the nurses had a bachelor's degree in nursing, and more than half (n = 1,566; 52.50%) of the nurses had worked in the hospital for 5 or fewer years. With 100 points being the highest possible score for the CD-RISC 25, the average score of nurses was 61.35 ± 13.12.
Relationship Between Demographics and Resilience Scores
There were significant relationships between nurse resilience and age, education, clinical rank, and years of employment (p < .05). Nurses older than age 45 years had the highest resilience scores (65.88 ± 13.43), and nurses between ages 26 and 35 years had the lowest scores (60.00 ± 13.21). Regarding education, nurses with a master's degree or higher had the highest resilience scores (63.62 ± 12.38), and nurses with an associate degree had the lowest scores (49.80 ± 23.09). Nurses with the highest clinical rank (level IV deputy chief nurses) had the highest resilience scores (69.16 ± 12.06). Regarding years of employment, nurses who worked in the hospital for more than 20 years had the highest resilience scores (65.11 ± 13.84) and nurses who worked in the hospital for 6 to 10 years had the lowest resilience scores (60.00 ± 13.21). There were no significant relationships between nurse resilience scores and gender, marital status, units where nurses worked, or type of employment. Demographics, resilience scores, and the univariate analysis are summarized in Table 1.
Demographics and Resilience Scores of Participants
Demographic Factors Influencing Nurse Resilience
Using nurse resilience scores as an outcome variable and the variables that were statistically significant in the univariate analysis as independent variables, a stepwise multiple regression analysis was conducted. The final variable entering the regression equation was nurses' years of employment (p < .05), which was a significant predictor of nurse resilience in the hospital.
Stressors Triggering Job-Related Stress
Participants identified nine job-related stressors. These stressors included monthly supervisor inspections (n = 2,211, 74.17%), monthly nursing knowledge and clinical skill examinations (n = 1,773, 59.48%), heavy workloads (n = 1,731, 58.07%), low wages (n = 1,469, 49.31%), conflicts with patients (n = 1,189, 39.89%), mandatory overtime and shift changes (n = 1,182, 39.65%), few promotion opportunities (n = 913, 30.63%), research requirement (n = 769, 25.80%), and work-life imbalance (n = 673, 22.58%).
Ways Perceived to Promote Resilience
Nurses reported five main ways that nurse leaders could help them relieve job-related stressors and promote resilience. These strategies included improving work benefits (n = 2,702, 90.64%), reducing workload (n = 2,199, 73.77%), providing flexible scheduling (n = 2,189, 73.43%), offering psychological counseling (n = 1,251, 41.97%), and increasing opportunities for professional training (n = 895, 30.02%).
This study measured the resilience of nurses, assessed the relationships between demographic factors and resilience, and identified job-related stressors and ways to reduce stress. The findings showed nurse resilience was significantly correlated with age, education level, clinical rank, and years of employment but not with gender, marital status, work unit, or type of employment. Nine major job-related stressors were identified: monthly supervisor inspections, monthly nursing knowledge and skill examinations, heavy workload, low wages, conflicts with patients, mandatory overtime and shift changes, few promotion opportunities, research requirement, and work-life imbalance.
An interesting phenomenon, however, was that perceived job-related stressors did not match precisely with perceived ways to release the stressors. The strategies that nurses perceived as helpful were improving work benefits, reducing workload, providing flexible schedules, offering psychological counseling, and increasing opportunities for professional training. Although it was a limitation of the study that the precise reasons for the nurses' responses were not known, one possible explanation could be that nurses might have shifted their focus and assigned new meanings to the required inspections and examinations.
As health care reform continues to progress globally, patient care quality has become the top priority for hospitals. Hospitals need highly qualified and competent nurses to be prepared for inspections to meet various safety and credentialing requirements. In China, it is essential for hospital and nurse leaders to closely monitor nurses' practices and professional competencies (Gao, Hou, & Liu, 2016). Examples of monthly inspections are inspections and examinations of nursing knowledge and technical skills. Because of the necessity to maintain competencies in nursing, nurses might have shifted their focus and assigned new meaning to the examinations and inspections.
These new meanings could be that inspections and examinations were mandatory by the hospital and were necessary to keep nurses competent in nursing practices. Nursing is a knowledge-based profession, and to maintain competency, nurses must remain current in their nursing knowledge and skills; thus, nursing is a lifelong learning process (American Nurses Association, 2015). Even though nurses felt it was hard to undertake the monthly inspections and examinations, they acknowledged the importance to complete them and thus shifted their focus from burden to necessity.
This rationale can be supported by the science on resilience, which has shown that resilience training can change the brain and individuals' attitude and behavior (Tabibnia & Radecki, 2018). It usually takes time to institute policy changes, such as improving benefits and reducing workloads. While waiting for the policy to change, nurse leaders may collaborate with resilience trainers, such as psychological counselors, to help nurses be optimistic and focus on the things that they can change. Nurses in this study indicated they would like to receive help from psychological counselors.
Nurse leaders in the United States have started to collaborate with resilience trainers, such as psychological counselors, social workers, and hospital chaplains, to develop educational seminars and activities to help nurses build resilience (Kester & Wei, 2018; Wei, Roberts, Strickler, & Corbett, 2019). The strategies that nurse leaders applied to foster resilience included facilitating nurses' social connections both inside and outside the work setting, promoting positivity at work, maximizing nurses' strengths and expertise, nurturing nurses' professional advancement, promoting nurses' self-care, cultivating mindfulness practice, and being authentically present for nurses (Wei et al., 2019). Nurse leaders play a significant role in improving nurses' professional growth (Wei, Sewell, Woody, & Rose, 2018) and promoting a caring environment for nurses and patients (Wei & Watson, 2019). Being authentically present is a valuable asset for nurse leaders to support their nurses (Yoder-Wise & Benton, 2017).
The highest possible score on the CD-RISC is 100. For the participants in the current study, the average resilience score was 61.35 ± 13.12, which is lower than scores reported for the general public in the United States and China, and also for nurses in developed countries. The mean CD-RISC score among a general U.S. population (n = 577) was 80.4 ± 12.8 (Connor & Davidson, 2003), and the mean CD-RISC score among a Chinese population (n = 560) was 65.40 ± 13.90 (Yu & Zhang, 2007). In a study that examined the resilience of 2914 Chinese adolescents who had experienced a disastrous earthquake 2 months prior, the mean CD-RISC score was 69.64 ± 13.25 (Yu et al., 2011). Gillespie, Chaboyer, and Wallis (2009) surveyed 735 nurses who were members of the Australian College of Operating Room Nurses Association; the average resilience score of participants was 75.9 ± 11.0. For all of these studies, the resilience scores were higher than the nurses' scores in the current study, which indicates an urgent and pressing need for the hospital and nurse leaders to investigate ways to help nurses.
In this study, nurses' age and years of employment had a significant influence on nurse resilience. Nurses older than age 45 years who worked in the hospital for more than 20 years had the highest resilience scores. This finding brought attention on the psychological health of younger nurses. Previous research has specifically examined newly licensed nurses' retention rate and predictors for new nurses to leave their job. Blegen, Spector, Lynn, Barnsteiner, and Ulrich (2017) examined a sample of 97 hospitals in the United States. The findings showed that newly licensed nurses had an 83% retention rate, and nurses' education was a trending impact factor on retention, with nurses who graduated from traditional baccalaureate programs having a higher retention rate than nurses from associate, diploma, or accelerated degree programs; these findings are similar to the findings of this study. The findings of this study may encourage future research to include psychological health promotion strategies, such as resilience-building, in both nursing school education and hospital continuing education for nurses.
Implications for Clinical Practice
Nurses in this study indicated they wanted to see improvement in their work benefits, such as reduced workload, flexible schedules, psychological counseling as needed, and increased opportunities for professional training. Based on nurses' responses in the study and the current research, the following strategies are proposed for continuing education to help nurses build resilience:
- Provide opportunities for nurses to develop professionally, such as offering seminars for innovative nursing knowledge and skills.
- Offer classes to help nurses prepare for higher clinical ranks.
- Collaborate with resilience trainers to provide in-service to help nurses build resilience skills, such as shifting focus, practicing gratitude, and cultivating optimism.
- Arrange activities to encourage nurses to perform physical and emotional hygiene to reduce stress after heavy workloads, including adequate sleep, exercise, nutrition, and social support.
This study used a cross-sectional survey design to quantify nurse resilience and perceived stressors. This design limited our ability to understand nurses' perceptions from a full spectrum. One significant limitation was not knowing nurses' thoughts on ways to combat frequent managerial inspections and mandatory examinations; nurses did not mention strategies to solve these stressors. A follow-up study has been planned to examine nurses' personal experiences of resilience building and ways to reduce their stress in the specific work environment. Nonetheless, with a large sample size of nearly 3,000 nurses, this study provided a strong base for creating additional nurse resilience studies both in China and globally.
The nurses surveyed had a resilience score that was lower than the general public of the United States and China, as well as nurses in developed countries. The study indicated a pressing need for hospital leaders to find ways to reduce nurse work-related stress. Maintaining a healthy and resilient nursing workforce is fundamental for hospitals. Nursing is a profession with high levels of stress; without appropriate resources and education, nurse-perceived stressors may lead to decreased job satisfaction and job burnout. Resilience, being considered as an antidote to stress and burnout, can be taught through education and help nurses adapt to their stressful work environments. Building nurse resilience through continuing education and system change should be an important focus for nurse leaders.
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Demographics and Resilience Scores of Participants
|Characteristic||n (%)||Resilience (χ̄, s)||t/F||p|
| ≤ 25||876 (29.4)||63.11 ± 12.26||15.686||.000*|
| 26 to 35||1612 (54.1)||60.00 ± 13.21|
| 36 to 45||381 (12.8)||61.72 ± 13.77|
| > 45||112 (3.8)||65.88 ± 13.43|
| Male||165 (5.5)||62.83 ± 13.90||2.213||.137|
| Female||2816 (94.5)||61.27 ± 13.07|
| Married||1612 (54.1)||61.04 ± 13.53||2.103||.147|
| Single||1369 (45.9)||61.74 ± 12.62|
| Internal medicine||712 (23.9)||61.01 ± 13.43||.924||.487|
| Surgery||739 (24.8)||61.75 ± 12.12|
| Obstetrics/gynecology||149 (5)||63.39 ± 14.31|
| Pediatrics||224 (7.5)||60.75 ± 12.30|
| Intensive care unit||346 (11.6)||61.66 ± 11.74|
| Outpatient||572 (19.2)||60.80 ± 13.53|
| Operating room||189 (6.3)||61.51 ± 12.98|
| Other||50 (1.7)||61.04 ± 13.29|
| Staff nurse||1479 (49.6)||61.79 ± 12.53||7.728||.000*|
| Senior nurse||789 (26.5)||60.20 ± 13.72|
| Charge nurse||670 (22.5)||61.25 ± 13.53|
| Deputy chief nurse||43 (1.4)||69.16 ± 12.06|
| Vocational school||10 (0.3)||49.80 ± 23.09||5.018||.002*|
| Associate||714 (24)||62.32 ± 13.26|
| Bachelor||2189 (73.4)||61.03 ± 13.01|
| Master's and higher||68 (2.3)||63.62 ± 12.38|
|Type of employment|
| Contract-based||2331 (78.2)||61.23 ± 13.14||2.131||.119|
| Provisional contract-based||59 (2)||64.74 ± 9.63|
| Permanent||591 (19.8)||61.53 ± 13.33|
|Years of working|
| ≤ 5||1566 (52.5)||62.10 ± 12.66||11.574||.000*|
| 6 to 10||757 (25.4)||59.06 ± 13.36|
| 11 to 15||295 (9.9)||60.90 ± 13.01|
| 16 to 20||155 (5.2)||60.89 ± 13.99|
| > 20||208 (7)||65.11 ± 13.84|