Journal of Nursing Education

Major Article 

Learning to Bounce Back: A Scoping Review About Resiliency Education

Rebecca Low, MEd (HSE), BScN, RN; Sharla King, PhD; Caroline Foster-Boucher, MN, RN

Abstract

Background:

Health care professionals face high levels of stress from working in a demanding environment. Resiliency training has emerged as an approach to overcome occupational stress. The purpose of this study was to understand what is known about educational strategies for teaching resilience.

Method:

The five-stage approach from Arksey and O'Malley was used as the methodological framework. Resources were evaluated thematically to identify key strategies and interventions.

Results:

Included resources (N = 25) were organized into six themes: (a) Reflective Practice; (b) Storytelling; (c) Peer Support and Mentoring; (d) Professional Support and Mentoring; (e) Mindfulness and Meditation Practice; and (f) Enhancing Self-Knowledge and Personal Competencies.

Conclusion:

This scoping review has confirmed that there are relevant education strategies to assist students in developing resilience. Recommendations for integrating resilience education at the undergraduate level are included. Preparing nursing students to persevere through adversities is essential for maintaining physical, mental, and emotional health throughout their career. [J Nurs Educ. 2019;58(6):321–329.]

Abstract

Background:

Health care professionals face high levels of stress from working in a demanding environment. Resiliency training has emerged as an approach to overcome occupational stress. The purpose of this study was to understand what is known about educational strategies for teaching resilience.

Method:

The five-stage approach from Arksey and O'Malley was used as the methodological framework. Resources were evaluated thematically to identify key strategies and interventions.

Results:

Included resources (N = 25) were organized into six themes: (a) Reflective Practice; (b) Storytelling; (c) Peer Support and Mentoring; (d) Professional Support and Mentoring; (e) Mindfulness and Meditation Practice; and (f) Enhancing Self-Knowledge and Personal Competencies.

Conclusion:

This scoping review has confirmed that there are relevant education strategies to assist students in developing resilience. Recommendations for integrating resilience education at the undergraduate level are included. Preparing nursing students to persevere through adversities is essential for maintaining physical, mental, and emotional health throughout their career. [J Nurs Educ. 2019;58(6):321–329.]

Health professionals work in dynamic settings and are faced daily with environmental, organizational, and personal challenges (McAllister & McKinnon, 2009). Occupational demands include coping with constant administrative changes, staffing and resource shortages, increasing patient workloads, lack of support, and role ambiguity (Beddoe, Davys, & Adamson, 2013; McDonald, Jackson, Vickers, & Wilkes, 2013). The detrimental impact of experiencing chronic workplace stress can result in career dissatisfaction, professional burnout, attrition, and risk for patient safety (Jackson, Firtko, & Edenborough, 2007; Kinman, McMurray, & Williams, 2014; Wald, Haramati, Bachner, & Urkin, 2016). Managing these diverse challenges in the workplace requires the ability to endure stress and confront emotional strain (McDonald et al., 2013). Unfortunately, individuals who enter a caring profession, such as nursing, tend to put the needs of others before themselves and often struggle to find a balance between work and self-care (Skovholt & Trotter-Mathison, 2011). An essential attribute for working in health care is resilience (Hodges, Keeley, & Grier, 2005).

Resilience is recognized as a multifaceted attribute that involves intrapersonal and environmental factors (Beddoe et al., 2013; McDermid, Peters, Daly, & Jackson, 2016). The intrapersonal characteristics of a resilient individual include a disposition of control, altruism, responsiveness, self-confidence, and positivity. The environmental influences include peer and social support, as well as a sense of belonging (McAllister & McKinnon, 2009; Tusaie & Dyer, 2004). It is important to acknowledge that the terms resilience and resiliency are used interchangeably throughout the literature. For the purpose of this review, both resilience and resiliency are defined as the presence of positive coping skills during adverse experiences and the ability to self-regulate and move forward in a constructive manner following challenging situations (Beddoe et al., 2013; Jackson et al., 2007).

The concept of demonstrating and developing resilience in the workplace has been explored to understand how certain health professionals survive and thrive in times of adversity (McAllister & McKinnon, 2009, p. 375). Studies regarding resilience in the health professions have primarily focused on the characteristics of resilient groups and individuals and identifying protective factors and strategies that build resilience (Beddoe et al., 2013; Hunter & Warren, 2014; McDermid et al., 2016; McDonald, Jackson, Vickers, & Wilkes, 2016; Wilks & Spivey, 2010). Research provides evidence to support the idea that resilience is an attribute that can be learned and developed in the education setting (McAllister & McKinnon, 2009). However, a clear and comprehensive understanding of specific educational strategies to develop resilience is lacking.

Resiliency must be taught, as novice practitioners will not passively acquire the necessary skills to adapt to the stressful work environment (Hodges et al., 2005). Although education cannot change the nature of the workplace, educators can influence student preparation and practice in order to overcome issues (Hodges et al., 2005). Educators help prepare nurses to be professionals and have the opportunity to influence environmental factors and emphasize interpersonal protective factors that build resilience (Hodges et al., 2005; McAllister & McKinnon, 2009). Resilience can be enhanced in educational settings that are positive, are encouraging, and promote supportive peer and social communities (McAllister & McKinnon, 2009).

The purpose of this review is twofold: (a) to identify educational strategies to develop resilience in undergraduate health science students, and (b) to examine the application of these strategies to undergraduate nursing education. Literature from education, psychology, social work, medicine, midwifery, and nursing was included in this review to examine various approaches to teaching and developing resiliency. Strategies applicable to these associated professions are considered relevant to nurses and can be used in education for undergraduate nursing students who face comparable work-related adversities.

Method

The five-stage approach from Arksey and O'Malley (2005) was used as the methodological framework for completing this scoping review. The stages include (a) identifying the research question; (b) identifying relevant studies; (c) study selection; (d) charting the data; and (e) summarizing and reporting the results.

Identifying the Research Question

The aim of this study was to present a comprehensive review of the literature regarding educational strategies for learning, enhancing, and developing resiliency in undergraduate health science students. Because this research area is still developing in the nursing profession, a broad question and search strategy including allied professions was necessary to capture all relevant research on this topic. The research question guiding this review was: “What educational strategies have been identified to develop resilience in undergraduate health science students?”

Identifying Relevant Studies and Study Selection

An electronic literature search was conducted using CINAHL®, Medline®, ERIC, PsycINFO®, and EBSCO discovery service databases between 2005 to 2018. These searches used a combination of the following key terms: health profession* OR nursing OR social work OR teacher* AND resilience or resiliency or resilient AND professional development OR post-secondary or college or university or higher education AND education strategies. A number of articles from the field of education were identified and included to ensure all relevant literature was captured. A hand search of articles was completed to identify any missed resources. This review included all studies available in the English language that identified and evaluated education methods geared toward increasing resiliency in undergraduate students and practicing health professionals, in any postsecondary program and health care setting. Additional specifications included peer-reviewed and academic journals. The literature search and article identification are outlined in Figure 1.

Flow diagram for literature search and article identification.

Figure 1.

Flow diagram for literature search and article identification.

Charting the Data and Summarizing and Reporting Results

The descriptive-analytical method outlined by Arksey and O'Malley (2005) was used to evaluate each resource and chart key information relevant to the review objective. Each resource was evaluated thematically to identify key strategies and interventions for developing resilience. The results were organized according to identified themes.

Results

Six key themes related to strategies and approaches to resiliency education were identified from the review: (a) Reflective Practice; (b) Storytelling; (c) Peer Support and Mentoring; (d) Professional Support and Mentoring; (e) Mindfulness and Meditation Practice; and (f) Enhancing Self-Knowledge and Personal Competencies. Table 1 outlines the themes matched to the literature.

Summary of Themes and Strategies to Develop ResiliencySummary of Themes and Strategies to Develop Resiliency

Table 1:

Summary of Themes and Strategies to Develop Resiliency

Reflective Practice

Reflective practice was identified in 11 articles as a key strategy to develop resiliency. Reflection is the process of purposefully recalling a situation to discover its purpose or meaning (Potter & Romyn, 2013, p. 148). Three main approaches specific to developing resiliency were written reflection, strength-based reflection, and group reflection.

Written Reflection. Developing reflective skills through interactive writing has been associated with reducing stress, increasing well-being and empathy, and establishing a meaningful understanding of professional identity (Wald et al., 2015). For instructors, the process of interactive reflective writing involves giving students structured reflection questions and providing confidential written feedback, which facilitates an interactive process of sharing (Wald, Reis, Monroe, & Borkan, 2010). It is believed that structuring questions around wellness themes may build resilience and enhance professional identify development (Wald et al., 2015, p. 755). Writing helps cultivate self-awareness, provides the opportunity to identify connections between resilience theory and practice, and serves as a method to develop a resiliency plan for future practice (Kreitzer & Klatt, 2017). Reflective writing is a useful approach to creating new perspectives and gaining insights following a negative experience, as the process provides the opportunity to explore positive approaches to the situation (Jackson et al., 2007). The time away from the hectic practice area to examine and clarify one's own interpretations of the world creates a trail of transformative “A-ha!” moments because writing thoughts and feelings down allows one to revisit, share, and validate them (Hodges et al., 2005, p. 553).

Strength-Based Reflection. Strength-based reflective approaches have proven to be effective in resiliency development through focusing on solutions and strengths and student–instructor collaboration following difficult experiences (Delany et al., 2015; Hodges et al., 2005; Leroux & Théorêt, 2014; McAllister & McKinnon, 2009; McDermid et al., 2016). Hodges et al. (2005) recommended helping students reframe negative experiences by reflecting on their learning and what could be changed to help encourage strengths rather than emphasize failures (pp. 551–552). This approach aligns with theories of positive psychology in that strengths are the focal point. Reflections should be focused on approaches that engage students in exploring development of strengths, identity building, and leadership through questions such as “What can I learn to do to show others how to act with engagement, respect, and partnership?” (McAllister & McKinnon, 2009, p. 375). Delany et al. (2015) discussed introducing students to coping strategies from positive psychology by using statements based on strengths and past experiences, logging achievements, and linking current learning to long-term career goals. Students reflected on their actions, thoughts, feelings, and outcomes of using positive coping strategies when faced with stressors and identified increased cognitive control and confidence (Delany et al., 2015).

Group Reflection. Two studies identified that the group reflection process helped build resilience for students (Bass, Walters, Toohill, & Sidebotham, 2016; Kreitzer & Klatt, 2017). In one study, student support circles were facilitated, and students reflected as a group on topics such as midwifery philosophy, ethics, culture, and self-care. Structured reflective questions such as “How am I developing my sense of identity as a midwife?” were presented, and students were encouraged to share personal stories and experiences (Bass et al., 2016, pp. 114). Students reported that guided group reflection helped increase their confidence and resilience through sharing a sense of connection and belonging with their peers. Using an organized approach to reflect and share stories was identified as a significant way to increase students' self-awareness and sense of identity, which has been attributed to developing resilience (Bass et al., 2016). Students identified that weekly reflective group discussions to share learning experiences, stress management, and resiliency development practices contributed to decreased stress and created “community and connection” (Kreitzer & Klatt, 2017, pp. 156).

Storytelling

Three resources identified storytelling as an integral approach for teaching resilience (McAllister & Lowe, 2011; Meyer, Licklider, & Wiersema, 2009; Ng & Nicholas, 2015). Storytelling is a tradition that invites introspection, questioning, and acts as an illustrative vehicle to transform abstract concepts into concrete understanding. McAllister and Lowe (2011) used stories to explore themes of resiliency in the nursing profession. Numerous topics, ranging from reacting to stress to coping with a crisis, were introduced through the use of storytelling and corresponding reflection exercises and activities (McAllister & Lowe, 2011). Meyer et al. (2009) used the pedagogy of storytelling as a method for enhancing students learning and acquisition of resiliency. The authors acknowledged that self-awareness is a key aspect to developing resilience, and the course enabled students to examine their own self-story to develop an understanding of themselves in relation to resiliency. Ng and Nicholas (2015) used digital storytelling as an innovative approach to develop resilience in education students. The students were instructed to make and share their own digital story depicting a time they experienced adversity in their teaching practicum and how they resolved the situation. Digital stories were created using a web-based social tool called VoiceThread, which creates videos that combine narratives with text, images, and sound in a movie format. The study found that using digital stories prompted reflection, peer feedback, discussion, and support and was an effective approach to enhancing student resilience (Ng & Nicholas, 2015).

Peer Support and Mentoring

The necessity of peer support and mentoring for developing resiliency was discussed in four articles (Hunter & Warren, 2014; McAllister & McKinnon, 2009; McDonald et al., 2016; Wilks & Spivey, 2010). Peer support was identified as the single most significant defense against workplace adversity among nurses and midwives (McDonald et al., 2016). Research findings indicated that opportunities to debrief and share knowledge and experiences with peers created a sense of mutual understanding and belonging, acted as a coping mechanism, and contributed to a shared sense of resilience. McDonald et al. (2016) recommended facilitating opportunities for peers to share their knowledge about strategies to overcome workplace difficulties. Educators have a responsibility in nurturing peer support to help students establish professional resilience (Wilks & Spivey, 2010). Recommendations included implementing peer support strategies into programs through funding student organizations, facilitating interactive social events, building stress-free peer zones, and offering peer mentoring opportunities to share experiences and explore stress-management strategies (Wilks & Spivey, 2010, p. 285). Senior students can share their “clinical survival tips” and experiential knowledge with students in the earlier stages of the program (McAllister & McKinnon, 2009, p. 376). Peer support has reciprocal benefits to enhancing resilience in both those who receive and those who provide emotional support (Hunter & Warren, 2014). Offering peer support provides the opportunity to collectively reflect and role model resilient approaches to coping with difficulties.

Professional Support and Mentoring

Five articles indicated that effective supervision, guidance, and mentoring contributed to resiliency by reducing negative effects of workplace stress, increasing positive outcomes and awareness of stressors and coping mechanisms, and developing a professional identity (Beddoe et al., 2013; Hodges et al., 2005; Kreitzer & Klatt, 2017; McAllister & McKinnon, 2009). Students often struggle with self-doubt, making them vulnerable to workplace intimidation and at risk for being marginalized, disregarded or exploited (McAllister & McKinnon, 2009). Hodges et al. (2005) presented Parse's human science theory, the Human Becoming School of Thought as a framework for promoting resilience in undergraduate nursing education. This framework encourages meaningful student–faculty collaboration that explores personal and philosophical understandings of caring and how to develop strong professional values and identities (Hodges et al., 2005, p. 550). Developing a professional identity and value system requires time, education, encouragement, and emphasis from faculty members (Hodges et al., 2005). The literature specified that mentorship from experienced professionals helps novice practitioners develop values such as recognizing the significance of public service and importance of contributing to society. This further helped develop a passion for work and contributed to a sense of “belonging to a professional family” (Hunter & Warren, 2014, p. 930). Opportunities to work with positive role models throughout social work education helped students to build a positive, resilient professional identity (Beddoe et al., 2013, p. 113). McAllister and McKinnon (2009) reported that imitative learning is viewed as a valuable educational strategy and emphasized the need for educators to role model personal resilience and growth by sharing their own experiences and knowledge gained from adversities. This could also include sharing among professional colleagues at seminars and conferences, or through publications (McAllister & McKinnon, 2009). Students reported that interviewing a health professional about workplace challenges, strategies for resiliency, and approaches to practicing mindfulness allowed them to develop a resiliency plan for future practice (Kreitzer & Klatt, 2017).

Developing Mindfulness and Meditation Practice

Three articles indicated that mindfulness and meditation practice were introduced in medical schools as an approach to reduce student stress and promote knowledge, skills, and attitudes for nurturing resilience (Kreitzer & Klatt, 2017; Wald et al., 2015; Wald et al., 2016). Mindfulness is defined as the ability to focus one's attention on the present moment and acknowledge and accept feelings and thoughts without judgment (Parkes & Kelly, 2014). Practicing mindfulness enhances stress resilience, relational skills, and cognitive control and attention (Kreitzer & Klatt, 2017, p. 157). A 7-week mindfulness-based course was integrated in the second year of medical school (Wald et al., 2015). The framework for this course included meditation activities along with discussion and reflection on topics such as developing self-awareness, cultivating compassion for self and others, and responding to loss and grief (Wald et al., 2015, p. 756). Delany et al. (2015) discussed the use of mindfulness and controlled breathing as an effective strategy to decrease anxiety and negative behavioral responses to clinical stressors, increase cognitive control and confidence, and improve composure in the clinical setting. A mind–body medicine workshop for health care practitioners and students found that participants reported an increased understanding of burnout and resilience and identified that they were better prepared to use meditation to prevent burnout (Wald et al., 2016). Researchers recommended that educators offer a “professional tool kit” that combines mind–body medicine and interactive reflective writing to enhance resilience and increase professional fulfilment to serve as a preventative burnout measure (Wald et al., 2016, p. 526).

Enhancing Self-Knowledge and Personal Competencies

Seventeen resources identified that developing self-knowledge and personal competencies to recognize individual limitations was vital for developing resilience. Four key strategies to enhance self-knowledge and personal competencies were identified: (a) self-awareness, (b) emotional intelligence, (c) self-care, and (d) the ability to reframe stress (Bass et al., 2016; Beddoe et al., 2013; Delany et al., 2015; Hunter & Warren, 2014; Kinman et al., 2014; Kreitzer & Klatt, 2017; McAllister & Lowe, 2011; McDonald et al., 2013; Meyer et al., 2009; Pines et al., 2014; Serwint et al., 2016; Skovholt & Trotter-Mathison, 2011; Stallman, 2011; Steinhardt & Dolbier, 2008; Tait, 2008; Wald et al., 2015; Wald et al., 2016).

Self-Awareness. Developing self-awareness to enhance resiliency is discussed in five articles. Developing self-awareness as an educational strategy was previously mentioned in this review in relation to reflective practice (Bass et al., 2016); self-examination through storytelling (Meyer et al., 2009); and mindfulness and meditation practices (Wald et al., 2015; Wald et al., 2016). However, a study by Wald et al. (2015) evaluated an educational strategy exclusively focused on developing self-awareness through engaging medical students in emotionally and ethically challenging clinical scenarios with standardized patients. Each student played a role in one scenario, observed two other scenarios, and participated in a prebriefing and debriefing process with other students and faculty. The emphasis and focus in these scenarios were on the importance of self-awareness in stressful circumstances and developing the ability to recognize unhelpful emotional responses such as blaming or distracting, while attempting to remain in the present moment. McDonald et al. (2013) reported on a work-based resilience workshop that provided creative learning activities for nurses and midwives who were able to enhance self-awareness through self-expression (p. 137). The workshop methods enhanced self-awareness, problem solving, and promoting behavioral changes to support resiliency (McDonald et al., 2013).

Emotional Intelligence. Four articles discussed emotional intelligence, defined as a set of social and personal competencies that support people in understanding their own emotions and regulating their responses to others (Jackson et al., 2007; Tait, 2008). Research indicates that developing emotional intelligence corresponds with reflective practice and self-awareness, enabling practitioners to recognize their stress triggers or warning signs and take proactive steps to minimize impact and address stressors (Hunter & Warren, 2014; Jackson et al., 2007). Tait (2008) recommended discussing elements of emotional intelligence, such as self-assessment, self-regulation, empathy, and social skills and encouraging students to identify and discuss resilient responses to difficult experiences (Tait, 2008). Students may develop emotional intelligence by using scenarios, videos, and classroom observations of difficult situations to identify and practice coping strategies, emotional competence, and reframing skills (Tait, 2008). Nursing students were taught conflict resolution skills as an approach to strengthen resiliency through self-development of areas such as emotional insight (Pines et al., 2014). Although no substantial changes in stress resiliency were reported following the course, researchers encourage educators to incorporate conflict management strategies in the curriculum and provide students with ongoing opportunities to apply and practice using these strategies to prepare students for handling future workplace conflict effectively (Pines et al., 2014).

Self-Care. Self-care is defined as the “habitual maintenance of physical and emotional health and well-being” (McDonald et al., 2016, p. 129) and is acknowledged in six resources as a key component for developing and maintaining resilience (Beddoe et al., 2013; Kreitzer & Klatt, 2017; McDonald et al., 2013; Serwint et al., 2016; Skovholt & Trotter-Mathison, 2011; Stallman, 2011). Self-care involves any activity that one finds restorative and facilitates an avenue to reconnect with self and others and therefore is highly individualized from person to person. Educators can encourage students to identify and implement self-care strategies they find meaningful to promote well-being and professional exuberance by creating a self-care action plan (Serwint et al., 2016; Skovholt & Trotter-Mathison, 2011). Self-care was identified by social work practitioners as fundamental to career longevity and candid teaching about the importance of self-care is needed when educating students about resilience and coping strategies (Beddoe et al., 2013). Self-care techniques grounded in mind–body medicine practices such as relaxation therapy, guided imagery, meditation, and use of art, movement, and music, taught to medical students resulted in decreased stress and negative affect, and increased empathy and positive affect (Kreitzer & Klatt, 2017). In a strength-focused resilience-building seminar, six building blocks of resilience were introduced to enhance resiliency literacy and behaviors and included: (a) realistic expectations; (b) balance; (c) connectedness; (d) positive self-talk; (e) stress management; and (f) taking action. These building blocks were explored through didactic teaching, videos, group discussion, and optional reflective journaling, and students reported increased self-efficacy and implementation or planned implementation of the recommended strategies (Stallman, 2011).

Reframing Stress. Four resources identified the ability to reframe stress as a key element of self-knowledge and resilience (Delany et al., 2015; Kinman et al., 2014; Meyer et al., 2009; Steinhardt & Dolbier, 2008). Active coping strategies, such as positive reframing, are intended to transform the nature or perception of an issue and are considered an effective approach to managing stress (Kinman et al., 2014). As previously discussed, one approach to developing reframing is through the use of storytelling and examining stories that share illustrative examples of positive reframing (Meyer et al., 2009). Delany et al. (2015) discussed the impact of teaching students to focus on the process of learning versus the outcome of learning as a resiliency strategy to cope with stress associated with learning in the clinical setting. This strategy increased student confidence and cognitive control in stressful situations. Resiliency scores and effective coping strategies increased in students when they explored theories on stress response and focused on positive reframing as a coping strategy (Steinhardt & Dolbier, 2008, p. 451).

Discussion

This scoping review highlights the literature supporting the use of specific educational strategies to teach resiliency. The specific strategies to develop and enhance resilience were identified through six themes: (a) Reflective Practice; (b) Storytelling; (c) Peer Support and Mentoring; (d) Professional Support and Mentoring; (e) Mindfulness and Meditation Practice; and (f) Enhancing Self-Knowledge and Personal Competencies. These identified educational strategies can be applied to undergraduate health science education. For the purpose of this review, application to undergraduate nursing education is discussed in the recommendations.

Recommendations for Nursing Education

The relevance and need for resilience education in the health care profession is critical. In the nursing profession, the occupational demands are emotionally, cognitively, and physically challenging. Nurses have a significant amount of contact with vulnerable patients and are confronted daily with constant change, critical decision making, time constraints, and staff and resource shortages (McAllister & McKinnon, 2009; McDonald et al., 2013). New graduate nurses transitioning into the work setting are additionally confronted with the stress of adapting to their new role, potentially making errors, and interpersonal conflict with other nurses, contributing to low retention and high turnover rates (Rhéaume, Clément, & LeBel, 2011). Educators have the opportunity to prepare nursing students with strategies for resilience, as an approach to increase self-efficacy and prevent future career dissatisfaction, stress, burnout, and attrition (McAllister & McKinnon, 2009; McDermid et al., 2016). From this review, five recommendations for nurse educators have been identified.

Recommendation A. Introduce the concept of resiliency development in first-year nursing education. Specifically, defining resilience, exploring the attributes and behaviors of resilient individuals, and discussing the relevancy of resilience in the nursing profession could be incorporated along with other fundamental concepts, such as professionalism and communication. McAllister and Lowe (2011) explored these key components to understanding and developing resilience through research, personal stories, case studies, and reflective exercises in their book, which could be used as a resource to guide discussions and learning activities in the first year of the program. Discussions of preventing and managing stress through strength-based approaches such as setting realistic expectations, balance, connectedness, positive self-talk, and taking action could be incorporated through didactic teaching, videos, and providing students with a “Staying on Track Tip Sheet” (Stallman, 2011, p. 124). Presenting content on the physiology of stress, exploring common stressors, and professional burnout will provide students with a clear understanding of the relevancy of resiliency development (Wald et al., 2016). This information could be integrated into theoretical, clinical, and laboratory courses with relatively low cost.

Recommendation B. Incorporate activities for self-exploration to enhance self-awareness and develop personal competencies. Help students gain self-awareness by completing a resilience inventory test and reflect on identified strengths and vulnerabilities to develop insight (McAllister & Lowe, 2011, p. 19). Develop coping strategies and strengths by exploring questions such as “What do I need to know about what it takes to succeed out there?” and “How can I develop critical thinking, creative thinking, and a sense of humor to help me cope?” (McAllister & McKinnon, 2009, p. 375). Use storytelling to facilitate students to examine their own story to enhance self-awareness, develop an understanding of how emotions impact perceptions and reactions, explore opportunities for reframing challenges, and promote critical thinking and positive self-talk (McAllister & Lowe, 2011; Meyer et al., 2009). Share videos and case studies that explore common challenging situations nurses encounter and identify and practice coping strategies and reframing skills (Tait, 2008). Incorporate mindfulness practices and meditation to help students develop self-awareness, self-monitoring, recognize biases, address cognitive and emotional challenges at work, develop compassion for self and others, learn to respond to loss and grief, and decrease anxiety and negative responses to stress (Delany et al., 2015; Kreitzer & Klatt, 2017; Wald et al., 2015; Wald et al., 2016).

Recommendation C. Incorporate reflective practice activities that are strength-based with opportunities for peer sharing. Frame reflection activities through a lens that emphasizes solutions, strengths, and professional stamina, rather than focusing on problems (Hodges et al., 2005; Jackson et al., 2007). Use structured questions focused on wellness themes to guide interactive reflective writing and discussions, such as how to handle stress and uncertainty, develop self-compassion, and develop adaptive attitudes and coping skills (Kreitzer & Klatt., 2017; Wald et al., 2015). Further, provide opportunities to develop a professional identity by exploring questions such as “Who am I with this new professional identity?” and “How have I grown and developed as a student?” (Bass et al., 2016, p. 8; McAllister & McKinnon, 2009, p. 375). Use reflective practice to help students identify personal strengths and coping skills by reflecting on what strategies helped get them through past challenges and how those same strategies can be applied in their nursing practice (Delany et al., 2015). Structuring reflective discussions and providing the opportunity for students to share their stories and ideas and learn from one another promotes a professional identity, connection with peers, and self-efficacy (Bass et al., 2016).

Recommendation D. Acknowledge and teach the importance of self-care. Educators need to explicitly discuss the relevancy of self-care and the importance of personal well-being in the nursing profession and explore strategies to encourage students to identify and develop healthy practices early on (Beddoe et al., 2013; Kreitzer & Klatt, 2017; Serwint et al., 2016). Provide students with the opportunity to reflect on their current self-care practices, identify existing gaps, and develop and implement an individualized and comprehensive self-care plan at the start of each clinical experience (Kreitzer & Klatt, 2017; Serwint et al., 2016; Skovholt & Trotter-Mathison, 2011).

Recommendation E. Create a learning environment that promotes professional and peer support. Educators need to role model resilience strategies, share their personal stories, and work in collaboration with students to develop a resiliency plan for their future career (Beddoe et al., 2013; Kreitzer & Klatt, 2017; McAllister & McKinnon, 2009). The faculty should promote and support peer organizations, social events, designated “stress-free peer zones,” and support groups on campus, as well as reinforce the importance of community connection, open communication, and collaboration (Hunter & Warren, 2014; McDonald et al., 2016; McDonald et al., 2013; Wilks & Spivey, 2010). It is also necessary to acknowledge that discussions about resilience in relation to health care professionals and exploration of educational strategies to develop resilience are an emerging concept. Thus, it is important to recognize that instructors themselves may need education about resiliency and integration of the topic may need to be initiated at the faculty level.

Limitations

Two key limitations exist with the resiliency education literature. First, many of the studies on resiliency indicate that a small or self-selected convenience sample was used, which limits generalization to larger populations (Delany et al., 2015; Hunter & Warren, 2014; McDonald et al., 2013; Ng & Nicholas, 2015; Steinhardt & Dolbier, 2008; Wald et al., 2016; Wilks & Spivey, 2010). Second, studies involving resiliency education and implementation strategies are still in their infancy, as some curricula are in the early stages of implementation; therefore, further research and evaluation is needed to support changes to the curriculum (Serwint et al., 2016; Wald et al., 2015). For example, there is a need for research on the longitudinal impact of resiliency courses to substantiate the impact on burnout, compassion fatigue, and increasing resiliency and well-being (Kreitzer & Klatt, 2017). Studies evaluating the effects of using multiple approaches (Wald et al., 2015) and determining the optimal time to introduce resiliency concepts and strategies in nursing education (McDonald et al., 2013) are needed.

Conclusion

This scoping review has identified educational strategies to develop resilience in undergraduate health science students. Specifically, these strategies can be applied to nursing education. Before resiliency can be developed or enhanced, an understanding of the construct and its relevance to nursing education and practice must be established. Research has determined that there is a correlation between health professionals' resilience and well-being in the workplace, yet it is a concept that generally remains excluded from health professions education (McAllister & McKinnon, 2009). Introduction to the construct should include defining resilience in relation to health professionals, exploration of the attributes and behaviors of a resilient individual, and discussion of how resiliency is significant to handling work-related stressors. Students should be aware of the realities of workplace adversity and the negative influences stress may have on their health and well-being if left unmanaged. It is essential to know how to develop resilience as an approach to aid in overcoming workplace challenges and persevere in a demanding career (McDonald et al., 2016). Research demonstrates that “the development and maintenance of personal resilience may well be significant for sustaining physical, mental and emotional health across the span of a career” (McDonald et al., 2013, p. 139). The nursing profession by nature will inevitably expose individuals to challenging, stressful, and difficult situations. Therefore, focusing on developing and enhancing resilience in nursing students early in their career should be considered a critical approach to overcoming such adversities.

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Summary of Themes and Strategies to Develop Resiliency

ThemeStrategyReference
Reflective practiceWritten reflection
• Interactive writingWald, Reis, Monroe, & Borkan, 2010
• Structure questions around wellness themesWald et al., 2015
• Reexplore a negative experience to consider alternative positive approachesJackson et al., 2007
• Develop resiliency plan for future practiceKreitzer & Klatt, 2017
Strength-based reflection
• Focus on the learning in the experience not the failure or mistakesHodges, Keeley, & Grier, 2005
• Focus on solutions rather than problemsLeroux & Théorêt, 2014; McDermid, Peters, Daly, & Jackson, 2016
• Focus on the development of strengths, identity building, and leadershipMcAllister & McKinnon, 2009
• Reflection on use of positive coping strategiesDelany et al., 2015
• Case studies and reflection on past experiencesSerwint et al., 2016
Group reflection
• Student support circlesBass, Walters, Toohill, & Sidebotham, 2016
• Reflective discussionsKreitzer & Klatt, 2017
Storytelling• Use of stories that explore, highlight, and reflect on themes of resiliencyMcAllister & Lowe, 2011
• Examine self-story to develop an understanding of oneself in relation to resiliencyMeyer, Licklider, & Wiersema, 2009
• Use of stories on reframing stressMeyer et al., 2009
• Create digital stories as an opportunity for reflectionNg & Nicholas, 2015
Peer support and mentoring• Facilitate opportunities for peers to debrief and share knowledge and experiencesMcDonald, Jackson, Vickers, & Wilkes, 2016; Wilks & Spivey, 2010
• Fund student organizations, facilitate interactive social events, and build stress-free peer zonesWilks & Spivey, 2010
• Peer mentoring programsHunter & Warren, 2014; McAllister & McKinnon, 2009
Professional support and mentoring• Facilitate meaningful student–faculty collaboration (use of Human Becoming School of Thought as a framework)Hodges, Keeley, & Grier, 2005
• Mentorship to develop practice values and develop a professional identityBeddoe, Davys, & Adamson, 2013; Hunter & Warren, 2014
• Share personal stories of resilience and growth through challengesKreitzer & Klatt, 2017; McAllister & McKinnon, 2009
• Interview health professionals on strategies for resiliency
Mindfulness and meditation practice• Incorporate mindfulness-based course into curriculumWald et al., 2015
• Teach use of mindfulness-based coping strategiesDelany et al., 2015
• Participation in mind–body workshopWald et al., 2016
• Offer a professional tool kit that combines mind–body medicine and interactive reflective writing toolsWald et al., 2016
Enhancing self-knowledge and personal competenciesSelf-awareness
• Simulation with standardized patients to explore challenging clinical scenarios with emphasis placed on self-awareness of unhelpful emotional responsesWald et al., 2015
• Explore personal resilience and strengths through creative self-expression workshopMcDonald, Jackson, Wilkes, & Vickers, 2013
Emotional intelligence
• Discuss emotional intelligence and use scenarios and videos to explore challenging situations in practice to identify coping strategies, emotional competence, and reframing skillsTait, 2008
• Teach conflict resolution skillsPines et al., 2014
Self-care
• Encourage students to identify and implement self-care strategiesMcDonald et al., 2013; Skovholt et al., 2011
• Explicitly teach about the importance of self-care, resilience, and coping strategiesBeddoe et al., 2013; Kreitzer et al., 2017; McDonald et al., 2013
• Complete self-assessment and develop self-care planKreitzer et al., 2017; Serwint et al., 2016; Skovholt et al., 2011
• Teach self-care techniques grounded in mind–body medicine practicesKreitzer et al., 2017
• Introduce the six building blocks to prevent and manage stressStallman, 2011
Reframing stress
• Practice positive reframing following a challenging situationKinman et al., 2014
• Examine stories that demonstrate positive reframingMeyer et al., 2009
• Encourage students to focus on the process of learning versus the outcome of learningDelany et al., 2015
• Explore stress response theories & focus on positive reframing as a coping strategySteinhardt & Dolbier, 2008
Authors

Ms. Low is Faculty Lecturer, Faculty of Nursing, Dr. King is Associate Professor, Faculty of Education, and Ms. Foster-Boucher is Indigenous Nursing Coordinator and Faculty Lecturer, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Rebecca Low, MEd (HSE), BScN, RN, Faculty Lecturer, Faculty of Nursing, 4-228 ECHA, University of Alberta, Edmonton, AB, Canada T6G 1C9; e-mail: rebecca.low@ualberta.ca.

Received: December 21, 2018
Accepted: March 12, 2019

10.3928/01484834-20190521-02

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