To address the challenges in nursing education programs, nursing students can foster resilience, which is the ability to face adversity and move forward in a positive manner (Jackson, Firtko, & Edenborough, 2007). Resilience has been widely identified as a necessary process in nursing (Scammell, 2017; Traynor, 2017). Researchers have investigated resilience in nursing student populations. Evidence suggests that resilience enables nursing students to experience less burnout and improved academic outcomes (McGowan & Murray, 2016). There is some evidence that resilience may be related to academic success (Beauvais, Stewart, DeNisco, & Beauvais, 2014), although this was not supported elsewhere (Taylor & Reyes, 2012). It has been recommended that nursing student resilience be facilitated through the development of personal characteristics and social support (Stephens, 2013).
This research has focused on undergraduate or prequalification students, and there is a dearth of specific examples of how postqualification nursing students may foster their resilience. Postqualification is defined in this study as nurses who have achieved their professional registration and licensure and are pursuing additional nursing degrees (i.e., master's or PhD). There are no known studies that examine resilience processes in postqualification nurses. Knowing more about the process of resilience for these students may enable educators to enhance support for postqualification nurses in graduate programs. The aim of this study was to explore the process of resilience for nursing students in graduate programs.
Postqualification nursing students were interviewed once to learn about their experiences in postqualification education. This study was conducted using the Corbin and Strauss (2008) variant of grounded theory methodology. Ten participants formed a convenience sample voluntarily recruited through a graduate research course. A measure of saturation can often be achieved with six interviews and confirmed by up to 12 interviews (Guest, Bunce, & Johnson, 2006). Ten interviews were adequate to produce an acceptable qualitative sample.
Data were collected during face-to-face semistructured interviews at a location of mutual convenience, with an average length of 30 minutes. An interview guide, developed and applied by a student researcher, examined different aspects of the experience of graduate studies. The interviews were tape recorded and transcribed verbatim and verified by the participants prior to coding. This verification formed part of the efforts to ensure rigor in this research based on guidance by Morse, Barrett, Mayan, Olson, and Spiers (2002) for qualitative research.
There were no known risks to the participants in this study and participants were fully informed of how their data would be used. Participants were recruited as part of a peer research project and blanket institutional approval was provided for this coursework. Ten of the module's 24 students met the eligibility criteria and voluntarily consented to participate in this study. Participants signaled their consent by participating in the interview and data collection process, as was acceptable by the hosting institution. Each interview was made anonymous to the degree of student preference by removing identifying information. Participants had the opportunity to review transcripts before they were analyzed. Numerical codes were assigned to differentiate the interviews. Data were stored securely on a password-protected server in accordance with the Data Protection Act. There were no direct benefits to participants in this study and they did not receive any compensation for participation.
Data analysis began with reading each of the transcripts to become familiar with the data. Initially, three transcripts were coded with codes that were developed iteratively. Coding was approached as a process of identifying key concepts that are discussed by participants (Richards & Morse, 2013). Participants' own words were used as in vivo codes where possible. After reading the first three transcripts, the codes were reviewed to create a coding structure. The remainder of the transcripts were analyzed by applying this coding structure and developing new iterative codes where appropriate. The codes were then organized into larger categories and, subsequently, a grounded theory. Several iterative cycles of data analysis were completed to achieve a measure of theoretical saturation. The technique of constant comparison, where emerging findings are compared with other findings, was used as a theory-building strategy (Corbin & Strauss, 2008). Throughout the coding process, reference was made to the verification strategies of Morse et al. (2002) to ensure rigor through data analysis and theory development.
This study is part of a program of research on resilience, and the theoretical codes of awareness and managing (see below) were applied during analysis as appropriate. The application of theoretical codes enables a researcher to identify and account for sociological processes that are recognizable in research data (Hernandez, 2009). It is appropriate to integrate theoretical codes during analysis to demonstrate where previous understanding applies to original theoretical development (Glaser, 1978). After applying managing and awareness as theoretical codes, all of the transcripts were carefully reviewed to verify the appropriateness of using theoretical codes in this study.
Overall, participants explained their process of resilience as a response to the challenges of graduate education as illustrated in the Figure. Awareness was required to address these challenges and participants used various strategies to manage challenges. Participants reported both enjoying and struggling during their programs. This section outlines the findings of this study in detail, including a description of the participants, contextual factors, and a theoretically derived resilience process for postqualification nursing students.
Students' process of resilience.
The participants in this research study consisted of 10 postqualification nursing students from various backgrounds. Five nurses (50%) had completed mental health nursing education, and five (50%) had adult or generalist nursing education. There were eight master's students (80%) and two PhD students (20%), all in graduate nursing programs. All students were funded for their programs, except for one self-funding PhD student. Eight students (80%) were studying full time, with two (20%) studying part time. Information about age, gender, and race were not collected, as the recruitment pool was small, and those data may have made it possible for their colleagues to identify participants. In addition to personal characteristics, the context of this study was formed in part by the fact that the participants were studying at the same university in a large, international city.
The Resilience Process
Postqualification nursing students experience challenges associated with their programs and their personal lives. Students use awareness of these challenges to manage, facilitated by their passion and support. Students manage challenges by applying both metacognitive and practical strategies. If the challenges are addressed, students report that they are enjoying their programs. When students feel overwhelmed with challenges or unable to manage, they report that they are struggling in their programs. This process is cyclic and ongoing, and students may report different indicators throughout. A participant stated:
The journey that you go on, the stages that you go through… the real highs and lows of being like, that's great, I can achieve this, and then the next day you suddenly swing to I can't do this anymore, this is really difficult.
Participants identified facilitators as factors that helped them to be resilient. The process of managing is facilitated by two factors: passion or motivation, and perceived support. These factors are variable and fluctuate throughout students' time in their programs. Passion or motivation served as the impetus to apply for the program, and a sustaining factor throughout the program, especially during challenging times. One student said:
[I'll] use the skills I have developed on this course to make a . . .tangible change.
Perceived support facilitated student self-efficacy and enabled students' conceptual and practical development:
I'd met somebody that was inspirational, and they suggested I apply for funding.
The above factors are termed facilitators because these factors supported postqualification nursing student resilience and the practical completion of the research program.
Challenges consist of both intrinsic and extrinsic difficulties that students had overcome. Intrinsic challenges included a lack of confidence, self-doubt, or feelings of imposter syndrome. One student said:
I've probably got a lot of evidence to the contrary…I just don't know, I just feel like…I'm not…doing a good job.
Students struggled with uncertainty and adaptation to an academic setting. Extrinsic challenges included managing new responsibilities and competing priorities. A student commented:
At the end, it was so full on…. I'm a bit worried about that. That it becomes so all-consuming that my family life completely suffers.
Students reported that they had to learn to manage these challenges to complete their programs effectively.
Awareness was identified here as a driver of the postqualification nursing student process of resilience. Students reported that awareness was important for them to identify their resources, seek support, and take action:
I am really lucky to have professors around me to offer guidance and support.
Awareness was associated with the perceived sense of control. Students reported that when they were aware of their options they felt more in control of their studies and of their day-to-day schedules. Awareness enabled students to plan and apply strategies they learned from previous experiences.
The core category of resilience is managing for postqualification nursing students. Managing is how students balance competing demands with their perceived capacity. Managing takes two key forms: metacognitive strategies and practical strategies. Metacognitive strategies are those where participants reflect on their thought processes and included reframing, mindfulness, mental planning, and efforts to separate various responsibilities. One student stated:
I think you just have to work with what you've got, and you work with the best thing at that time.
Practical strategies included varying the location study, taking steps to avoid distractions, and organizing daily choices like commuting or clothing choices. A student commented:
Focus on what you are doing, be able to organize yourself, put everything on a schedule…. You have to get up and do it, not just stay in bed and sleep.
Students reported that they learned many of their strategies previously in both their clinical practice and prior education. Students applied these strategies based on previous successes and learning from previous failures:
At work, we had to do a lot of planning together…that's a skill I've gotten quite used to.
Although each student enacted resilience in a different way, they all applied both metacognitive strategies and practical strategies, reporting varying degrees of success.
Indicators represented how well students perceived they were managing their program challenges. Students reported enjoying it as the most positive indicator of their experience. Students identified enjoying the program as occurring when they felt a sense of accomplishment, competence, and confidence in their ability to move forward. A student said:
If a colleague asked me, I would say [I was] very excited and it was a huge opportunity.
Students described struggling as a counterpoint to enjoying it, stating that struggling occurred when they were unable to manage competing demands and were not achieving at a level that they found personally satisfying. Students report that they have learned from experiences where they were struggling from either previous education, clinical practice, or other life experiences. Students demonstrated that they apply this learning as postqualification students. This indicates that even negative experiences can have a cumulative effect of increasing students' resilience.
The process of resilience for postqualification nursing students bears similarities to other nursing resilience processes. Resilience has been conceptualized as a managing process for critical care nurses (Jackson, 2015). Both critical care nurses and postqualification nursing students manage in relation to adversity, which is facilitated by awareness. This suggests that by enhancing student awareness of adversity, it is possible to help students move toward resilient outcomes. The exposure to adversity for critical care nurses is location-specific, whereas the process of resilience for postqualification nursing students occurs in various locations, as their programs are not restricted to a clinical setting. The fact that students and critical care nurses both apply managing processes for their resilience may suggest that enhancing managing at an undergraduate student level may promote resilience throughout nursing careers.
The process of managing to develop resilience in postqualification nursing students bears similarities to another grounded theory of resilience. Fletcher and Sarkar (2012) studied resilience among gold medal athletes to determine how resilience enabled these athletes to reach the top echelons of their sports. They determined that athletes used metacognitive strategies and the appraisal of challenges to respond to stressors in an adaptive way and, thus, favorable outcomes. Perceived support, motivation, confidence, focus, and personal characteristics were important for gold medal athletes. This suggests that the use of metacognitive strategies may benefit varied populations in supporting resilience processes.
Comparison can also be made between resilience processes in pre- and postqualification nursing students. Andrusyszyn, Iwasiw, Forchuk, and Babenko-Mould (2015) found that students had to “push through” challenges to be resilient. Both pre- and postqualification students viewed adversity as a series of challenges, which involved balancing demands from multiple domains of life. It was agreed that resilience can be affected during nursing education programs. The main difference between the study by Reyes et al. (2015) and the current study is that “pushing through” is conceptualized as a learning, developmental process. In the current study, participants discussed resilience as resulting from the application and refining of a resilience process, rather than new learning. This strongly suggests that nurses apply resilience processes they learned in their previous education to their postqualification studies. This finding underscores the need for resilience education at a prequalification level.
This study is limited by several factors. The decision to collect minimal demographic information protected the participant confidentiality, but limits the generalizability of the findings. The purpose of qualitative research is not to create widely generalizable conclusions; thus, the findings of this research study should be applied cautiously.
The findings of this study suggested that managing is an important resilience process for postqualification nursing students. This study adds to the literature on resilience for nursing students, which is still developing. Researchers can explore how nursing students learn resilience processes to determine how educators can support the development of resilience. It may also be advantageous to directly compare resilience processes among pre- and postqualification nursing student populations to understand. Subsequently, the development of strategies and interventions to support resilience processes may help students and affect rates of completion.