Journal of Psychosocial Nursing and Mental Health Services

CNE Article Supplemental Data

Resilience in Baccalaureate Nursing Students: An Exploration

Deborah A. Lekan, PhD, RN-BC; Terry D. Ward, PhD, RN; Ashley A. Elliott, BSN, RN

Abstract

The purpose of the current study was to explore resilience in senior-level baccalaureate nursing students. Twenty-seven participants completed an online questionnaire assessing three stressors that pertained to marriage or divorce, death or loss of family members or close friends, and extreme financial hardship in the past 1 year. Resilience was measured using the 25-item Connor-Davidson Resilience Scale (CD-RISC-25) and one open-ended question about the experience of resilience. Mean CD-RISC-25 score was 73.26 (SD = 10.7; range = 45 to 96); only 33.3% of the sample was considered resilient (score >80). Qualitative data described academic stressors and support resources for resilience. Study findings underscore the relevance of resilience in nursing students. Nurse educators must help nursing students develop resilience to better prepare them for academic success and ensure a smooth transition into their professional nursing role. [Journal of Psychosocial Nursing and Mental Health Services, 56(7), 46–55.]

Abstract

The purpose of the current study was to explore resilience in senior-level baccalaureate nursing students. Twenty-seven participants completed an online questionnaire assessing three stressors that pertained to marriage or divorce, death or loss of family members or close friends, and extreme financial hardship in the past 1 year. Resilience was measured using the 25-item Connor-Davidson Resilience Scale (CD-RISC-25) and one open-ended question about the experience of resilience. Mean CD-RISC-25 score was 73.26 (SD = 10.7; range = 45 to 96); only 33.3% of the sample was considered resilient (score >80). Qualitative data described academic stressors and support resources for resilience. Study findings underscore the relevance of resilience in nursing students. Nurse educators must help nursing students develop resilience to better prepare them for academic success and ensure a smooth transition into their professional nursing role. [Journal of Psychosocial Nursing and Mental Health Services, 56(7), 46–55.]

Nursing students' journey through their academic program is fraught with classroom and clinical challenges. Contemporary opinion indicates that resilience is a crucial skill needed to thrive and survive in stressful situations and a critical competency for the 21st century (McAllister & Lowe, 2011; Sanderson & Brewer, 2017).

A growing body of evidence has established the relevance of resilience in nursing education and supports the concept that enhancing resilience will better prepare nursing students for academic success (Chamberlain et al., 2016). Ríos-Risquez, García-Izquierdo, Sabuco-Tebar, Carrillo-Garcia, and Martinez-Roche (2016) note that nursing students in their final year of school report a lack of fulfillment of expectations and disappointment that the high responsibilities of the nursing profession could stretch them beyond their capacities. Resilience will help them face and respond to academic challenges and bounce back when faced with setbacks or other adversities (Reyes, Andrusyszyn, Iwasiw, Forchuk, & Babenko-Mould, 2015a). Students who learn to be resilient will also make a smoother transition into their professional nursing roles, which is important in increasingly complex and chaotic health care environments (Hodges, Troyan, & Keeley, 2010; Reyes et al., 2015a; Stephens, 2013).

A focus on resilience in nursing education is necessary for the development and implementation of strategies to positively influence academic success and retention of students in nursing programs. The purpose of the current study was to explore resilience in nursing students enrolled in a baccalaureate nursing program and offer recommendations for resilience enhancement in nursing education.

Background

Nursing students typically experience high levels of stress due to the intensity and demands of the academic environment combined with financial, family, or other stress. Academic sources of stress include a heavy workload, fear of failure, a competitive environment, and feeling stretched beyond one's capacity (Reeve et al., 2013). In the clinical setting, nursing students have reported stress associated with insecurity about their clinical competence and caring for patients experiencing symptoms such as pain. They have also reported stress associated with a fear of making mistakes, having interpersonal conflicts with patients and staff, providing intimate care to a male or female patient, and working with dying patients (Smith & Yang, 2017; Thomas & Revell, 2016). Personal stressors include psychosocial factors such as anxiety, depression, and lack of time with family and friends (Lo, 2002; Pitt, Powis, Levett-Jones, & Hunter, 2014).

Persistent levels of stress can put students at risk for psychological distress, emotional exhaustion, burn-out (Aburn, Gott, & Hoare, 2016; Stephens, 2013; Thomas & Revell, 2016), and impaired resilience (Sanderson & Brewer, 2017; Ward & Eisbach, 2013). Resilience plays an important role in student academic success and retention in academic programs (Beauvais, Stewart, DeNicso, & Beauvais, 2014). Hodges et al. (2010) assert that nurse educators are called on to apply innovative teaching strategies that promote lifelong skills for developing insightful, meaningful, and resilient critical practice. A focus on resilience in nursing education is necessary to positively influence the formation of mature and confident nursing students who think analytically and flexibly and engage in self-reflection to manage the stressors in their academic programs. Deliberate attention to resilience in the curriculum will ultimately aide in their transition to clinical practice as a graduate nurse (Chen, 2011; Reyes et al., 2015a).

Resilience

International research on resilience has increased considerably over the past 20 years and has evolved to better understand how people “bounce back” and manage various challenges they confront across the lifespan from a health and well-being perspective in contrast to a deficit or illness perspective (Windle, 2011). The word resilience originates from the Latin word resilia, which means the “action of rebounding” (Oxford Dictionary of American English, 2005). Merriam-Webster's (2018) online dictionary defines resilience, a term first used in 1807, as “the ability to recover from or adjust easily to misfortune or change.” According to the American Psychological Association (2014), resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress” (para. 4). In their study of nursing students, Laschinger and Grau (2012) further elaborate and define resilience as “an ability to bounce back from adversity and is commonly found in people who feel that life is meaningful and have a high capacity for improvisation and adaptation” (p. 284). In a comprehensive review of the concept, Windle (2011) offers this definition:

Resilience is the process of effectively negotiating, adapting to, or managing significant sources of stress or trauma. Assets and resources within the individual, their life, and environment facilitate this capacity for adaptation and “bouncing back” in the face of adversity. Across the life course, the experience of resilience will vary.

Different approaches to studying resilience have led to shifts in how resilience is viewed. Early researchers framed resilience as a fixed personality trait or attribute that was present or absent. Contemporary perspectives consider resilience to be a dynamic process that can be developed, taught, modified, or enhanced; it can also be an outcome (Reyes et al., 2015a; Sanderson & Brewer, 2017). Although common understandings of resilience indicate the ability to bend but not break, to bounce back, and perhaps even to grow in the face of adversity, these definitions do not fully reflect the complexity and multifactorial aspects of resilience (Southwick, Bonanno, Masten, Panter-Brick, & Yehuda, 2014). Determinants of resilience include interacting biological, psychological, social, cultural, and spiritual factors that influence how an individual responds to stressful experiences (Southwick et al., 2014). Similarly, in their historical review of the construct of resilience, Tusaie and Dyer (2004) discussed the complexity of the construct of resilience, which warrants exploration from a holistic perspective, because resilience may vary in different contexts of age, gender, social class, nation/culture, and family history. Other researchers reported that resilience exists on a continuum that may operate to differing degrees in adaptations to stressors pertaining to family life, social networks, the workplace, and the academic setting (Sanderson & Brewer, 2017).

Several concept analyses and review articles have established the relevance of resilience to nursing (Dyer & McGuinness, 1996; Earvolino-Ramirez, 2007; Hicks & Connor, 2013). In a correlational cross-sectional study of operating room nurses, Gillespie, Chaboyer, Wallis, and Grimbeek (2007) found significant correlations between resilience and hope, self-efficacy, coping, control, and competence, which underscored the relevance of resilience in nursing practice. In a qualitative study, Hodges, Keeley, and Troyan (2008) explored resilience in new graduate nurses and revealed that resilience facilitated transition into practice and reflection in their new role. In an integrative review on resilience in nursing students, Thomas and Revell (2016) identified nine reports that identified salient issues and highlighted the importance of faculty awareness about ways to promote students' resilience through working closely with students in advisement and the clinical and classroom setting.

In the development of a nursing diagnosis taxonomy, Ward and Eisbach (2013) identified three alterations in resilience: risk for compromised resilience, impaired individual resilience, and readiness for enhanced resilience. Risk for compromised resilience is defined as a potential decreased ability to sustain a pattern of positive responses to an adverse situation or crisis. Impaired resilience is an actual decreased ability to sustain a positive response to an adverse situation or crisis. Readiness for enhanced resilience is a pattern of positive responses to an adverse situation or crisis that is sufficient for optimizing human potential and can be strengthened (Ward & Eisbach, 2013). The nature of academic preparation for nursing practice puts nursing students at risk for alterations in resilience. Stressors in academic contexts may lead to ineffective coping during nursing studies and entry into nursing practice. Nursing students experience stressors that are unique to nursing education, which can lead to impaired resilience (Aloba, Olabisi, & Aloba, 2016). In a qualitative study using grounded theory, Reyes, Andrusyszyn, Iwasiw, Forchuk, and Babenko-Mould (2015b) identified a social process described as “pushing through” that reflected acts of resilience, but when impaired resilience exists, nursing students feel the pressures of family, extracurricular, and academic demands and feel ready to quit. When impaired resilience is present, individuals experience decreased interest in social and academic activities, low self-esteem, and elevation of stress (Ward & Eisbach, 2013).

Current understandings of resilience indicate that for resilience to exist, adversity, positive adaptation, and positive emotions must be present. By better understanding sources of stress and resilience in nursing students, nurse educators have a clearer basis for resilience-promoting interventions to facilitate student academic success and overall well-being.

Method

Design

The current study used a cross-sectional descriptive design. The setting was a large public university in the southeastern United States.

Participants

A convenience sample of senior-level students enrolled in the baccalaureate nursing program during the 2017 spring semester were recruited. Non-study personnel visited one class to describe the study and distribute an informational flyer to each student. In addition, flyers were posted throughout the School of Nursing building. The informational flyer described the study and directions on how to access an electronic link to the study questionnaire. The survey link was accessible to enrolled students only and was made available for 10 days.

Measures

Two instruments were used for data collection. The investigator-developed sociodemographic form collected information about age, gender, race/ethnicity, relationship status, having children, nursing assistant certification and employment, and having earned a previous college or university degree. Categorical responses were obtained for age to protect anonymity (<22 years, 23 to 30 years, ≥31 years). The survey included three yes/no questions about life stressors that occurred during the past 1 year, which were derived from the Holmes and Rahe (1967) Life Stress Index and pertained to marriage or divorce, death or loss of family members or close friends, and extreme financial hardship in the past 1 year. One open-ended question invited additional feedback from participants about anything else they would like to add about their experience with resilience as a nursing student.

The 25-item Connor-Davidson Resilience Scale (CD-RISC-25) was developed as a self-assessment tool to quantify resilience. This tool has been used to establish reference values for resilience in the general population and clinical samples and as a clinical measure to assess resilience in treatment response (Connor & Davidson, 2003). Written permission was obtained from the authors to use the instrument in the current study. The CD-RISC-25 items are rated on a 5-point Likert scale ranging from 0 (not true) to 4 (true nearly all the time). Respondents are asked to base their ratings on how they felt over the past 1 month. Total scores range from 0 to 100, with higher scores indicating greater resilience; resilience is defined by a score >80. The CD-RISC-25 has been validated in community populations, primary care outpatients, and various clinical populations (Connor & Davidson, 2003). High reliability (Cronbach's alpha = 0.89) and a test–retest reliability correlation of 0.87 have been demonstrated (Connor & Davidson, 2003). In a recent methodological review of resilience scales, the CD-RISC-25 received high-quality ratings on conceptual and theoretical adequacy and psychometric properties (Windle, Bennett, & Noyes, 2011). This instrument has been used in prior research on resilience in nursing students (Table A, available in the online version of this article).

Studies on Resilience in Nursing Students using the CD-RISC-10 (N = 8)Studies on Resilience in Nursing Students using the CD-RISC-10 (N = 8)Studies on Resilience in Nursing Students using the CD-RISC-10 (N = 8)

Table A:

Studies on Resilience in Nursing Students using the CD-RISC-10 (N = 8)

Procedure

The sociodemographic questionnaire and CD-RISC-25 scale were entered in Qualtrics software. An introduction to the survey described the study purpose and indicated that the survey was voluntary and would take approximately 10 minutes to complete. The survey link was de-identified (e.g., name, IP address). Upon submission of the completed survey, the system provided a link for participants to enter a drawing for one of five $10.00 gift cards.

Data Analysis

Descriptive statistics were used to characterize the sample for sociodemographic data and CD-RISC-25 score and included mean (SD) and range. CD-RISC-25 Likert scale responses and distributions were examined and analyzed quantitatively. Chi-square and bivariate linear regressions were performed to explore associations between sociodemographic variables and CD-RISC-25 score. Multiple linear regression was performed to explore predictors of resilience. Text responses to the open-ended question were explored and summarized. Analyses were performed using SPSS version 23.

Ethical Considerations

All study procedures were approved by the university institutional review board.

Results

Fifty-six students were eligible to participate; 27 (48%) completed the online survey. Participant sociodemographic characteristics are described in Table 1. Most of the sample was age 23 and older (70%), most were female (81%), Caucasian (59%), and married (48%), and seven (26%) participants had children. A majority had worked or currently worked as a certified nursing assistant (78%), and approximately one half had a previous college or university degree (48%). Participants reported that the top contributor of stress in the past 1 year was extreme financial hardship (48%), followed by death or loss of family members or friends (30%), and marriage or divorce (7%).

Sociodemographic Characteristics of Nursing Students (N = 27)

Table 1:

Sociodemographic Characteristics of Nursing Students (N = 27)

Mean CD-RISC-25 score was 73.26 (SD = 10.7; range = 45 to 96). Multiple regression analysis was used to assess associations between sociodemographic and stress-related variables and CD-RISC-25 score. Correlation analysis indicated statistically significant associations between relationship status (married or partnered), prior college or university degree, and death of a close friend or family member in the past 1 year and CD-RISC-25 scores. In multiple linear regression with these three predictors, the model was significant, and these three predictors explained 37% of the variance in CD-RISC-25 score (adjusted R2 = 0.366, F[3, 23] = 6.008, p = 0.004, 95% confidence interval [50.11, 89.65]). However, the direction of the relationship between having a prior college or university degree was not as expected. A negative beta coefficient indicated that for every 1-unit increase in prior educational degree, the resilience score will decrease by −0.375 (p = 0.032) (Table 2).

Multiple Linear Regression Analysis of Connor-Davidson Resilience Scale-25 Scores (N = 27)

Table 2:

Multiple Linear Regression Analysis of Connor-Davidson Resilience Scale-25 Scores (N = 27)

Seven participants offered subjective comments in response to the open-ended question. Not surprisingly, several identified that assignments and tests were stressful, especially when they occurred concurrently. Resilience strategies included reaching out to others in the support system, working hard, developing a “tough skin,” and seeking professional help to manage anxiety and depression to remain resilient. One student wrote:

Life tends to have a way of throwing curve balls your way whether it be health wise, family wise or in nursing school. I've found that if you remain strong, have a good support system, and work hard anything is possible.

Considering the relevance of resilience in nursing education, one participant's quote summed it up: “I would find it helpful to devote more time while in nursing school to build protective factors that enhance resilience.”

Discussion

Emerging evidence, including the results of the current study, underscore the relevance of resilience in nursing education. Therefore, one imperative of nurse educators should be to help students learn how to become more resilient. In the current study, approximately two thirds of participants responding to the web-based survey scored < 80 on the CD-RISC-25, the cut-point indicating resilience (Connor & Davidson, 2003). However, more than two thirds of participants reported the tendency to bounce back after illness, injury, or other hardship on the CD-RISC-25 item as often true or true nearly all the time. This ability to bounce back in the face of adversity is an important feature of resilience (Aburn et al., 2016; Stephens, 2013). At the individual level, personal agency contributes to negotiating adversity; however, the availability of a support network, including family and friends and other resources, such as counseling or psychological intervention, is also necessary (Crombie, Brindley, Harris, Marks-Maran, & Thompson, 2013; Tusaie & Dyer, 2004; Windle et al., 2011).

The CD-RISC-25 is one of the most widely used scales globally, and a short version, the CD-RISC-10, has been validated in various populations (Connor-Davidson Resilience Scale, n.d.). The tool is scored on a scale of 0 to 40, with higher scores indicating greater resilience. In a study comparing the CD-RISC-25 and CD-RISC-10 in Chinese rehabilitation patients, the reliability, sensitivity, and specificity were comparable between instruments and not statistically different (Peng et al., 2014). The current authors elected to use the CD-RISC-25 because it addresses five domains of resilience: (a) personal competence, high standards, and tenacity; (b) trust in one's instincts, tolerance of negative effect, and strengthening effect of stress; (c) positive acceptance of change and secure relationships; (d) control; and (e) spiritual influences (Connor & Davidson, 2003). In comparison, Aloba et al. (2016) identified a two-factor structure, “toughness” and “motivation,” for the CD-RISC-10. Several studies on nursing student resilience using the CD-RISC-10 are listed in Table A. In these studies, mean resilience scores ranged from 24 to 40. In post hoc analyses, the CD-RISC-10 score was calculated for the sample and mean resilience score was comparable, 28.63 (SD = 5.09, range = 19 to 40). These studies reflect a culturally diverse student population but homogeneity in age and gender, which contrasts with the diversity in age, gender, and educational background found in the current study sample.

Significant correlations between relationship status and resilience, having “close and secure relationships” scored as true nearly all the time on the CD-RISC-25 by all participants, and qualitative responses describing the importance of the support system in the current study collectively highlight the importance of social support in resilience. Other research similarly reports that having a close support system is an essential resource for resilience, which facilitates the ability to handle the rigorous demands of the educational program (Sigalit, Sivia, & Michal, 2017; Thomas & Revell, 2016). Research also emphasizes different social support resources (Crombie et al., 2013; Stephens, 2013). Peer caring has been shown to be significantly associated with resilience and subjective well-being in Chinese nursing students (Zhao, Guo, Suhonen, & Leino-Kilpi, 2016). Cultural factors may impact the types and amount of support needed by nursing students. Milne, Creedy, and West (2016) note that some cultures have a greater need for support due to close-knit extended family relationships; therefore, students may seek support from peers and faculty members. Nurse educators serve an important role in the social network of nursing students (Hurlington, 2010), and the quality of the educator–student relationship can strengthen student resilience and academic performance (Froneman, Du Plessis, & Koen, 2016). The age diversity in the current study suggests a wider range of potential support needs: students who are younger, single, and anticipating their career path may have unique support needs compared to older students who may be married with children, employed, and managing myriad obligations. Although the adage suggests that “with age comes wisdom” and implies that older students may demonstrate higher levels of resilience, adult learners often must confront ongoing, increasing, and competing demands on their time and cognitive resources (Valiga, 2012).

The current study is notable for the diversity in the sample in sociodemographic characteristics and life circumstances, in contrast to research that focuses on the traditional undergraduate student matriculating directly from secondary education (Table A). In the United States, the student population has become more diverse, a result of changing demographics and more opportunities to pursue a college education (Valiga, 2012). A surprising finding was that there were not significant correlations between sociodemographic variables and resilience; however, using multiple linear regression, having a prior college or university degree was found to be a negative predictor of resilience. Limited research exists on resilience and educational level. In a study of university nursing students in Hong Kong, post-graduate nursing students had significantly higher resilience scores compared to undergraduate nursing students (CD-RISC-10, 24.9 versus 23.8, respectively, p = 0.02) (Chow et al., 2018). Similarly, Pitt et al. (2014) found that senior-level nursing students had higher levels of resilience compared to junior-level nursing students. Research on the relationship between resilience and having earned a prior educational degree, as noted in 48% of the current sample, has not been reported in the literature. Financial hardship was also reported by approximately one half of students in the current study, which has been noted as a significant source of student stress in other studies (Milne et al., 2016; Smith & Yang, 2017). One might anticipate that these mature second-degree students would be advantaged by first-hand experience with academic success, greater emotional maturity in managing life complexities, and more effective coping resources and resilience to overcome stressful experiences (Smith & Yang, 2017). However, the academic and clinical demands of nursing education are often overwhelming and unlike other traditional academic programs. These students also have different needs and must juggle complex personal, work, and family obligations in addition to their academics. This juggling can often be a challenge to the resilience of even these more seasoned and mature students (Thomas & Revell, 2016).

The current study provides a snapshot of resilience, but student resilience may vary based on context and circumstances and the availability and adequacy of protective factors (Aloba et al., 2016; Earvolino-Ramirez, 2007; Sanderson & Brewer, 2017). Students may function with a high level of resilience in one domain, such as employment or social relationships, and low resilience in another domain, such as academe. Cultural factors could inform what may be considered success or indicators of resilience, and the concept of resilience may not be comparable across cultures (Windle, 2011). As illustrated in the current study, resilience is salient in nursing students, but a stronger knowledge of resilience, its natural history, and the ongoing development of protective factors and marshalling of resources can enhance a clearer framework for resilience enhancement strategies in nursing education.

Implications and Recommendations

Nurse educators play a significant role in fostering students' development of knowledge and skills related to nursing practice and preparing students for future practice as nurses who can adapt and influence changing scopes of practice and effectively function in complex health care environments (Thomas & Revell, 2016; Waddell et al., 2015). Attrition from academic programs is of concern because the need for baccalaureate nursing students prepared for practice is growing as the aging population increases, placing greater demands on the health care system (Boardman, 2016; Valiga, 2012). Nursing students may be at higher risk for attrition than other programs of study due to unique circumstances surrounding their degree (Boardman, 2016).

Previous investigations have shown that nurses working in clinical practice who cultivate resilience over the course of their career reduce their risk for anxiety, depression, and posttraumatic stress disorder (Mealer et al., 2012). Therefore, fortifying nursing student resilience during academic programs should be an imperative of nurse educators. Nurse educators must first contextualize the concept of resilience and operationalize resilience for the settings and experiences of nursing students. Stephens (2013) proposed that clarification of the concept of resilience will assist nurse educators and nurse researchers in developing evidence-based interventions and strategies aimed at fostering resilience. The dynamic nature of resilience suggests that resilience is a changeable phenomenon that can be learned, taught, and cultivated (Reyes et al., 2015b). Thus, faculty and students need to contextualize resilience as a process that can be strengthened (Beauvais et al., 2014; Crombie et al., 2013).

Researchers have made clear recommendations for resilience enhancement and resilience training in nursing education (Aburn et al., 2016; Thomas & Revell, 2016). In a recent scoping review of 36 articles on resilience training in the health professions, Sanderson and Brewer (2017) identified nine studies on resilience training; five were in nursing. Four elements to consider in resilience training include personal resources and protective factors, contextual resources, strategies, and outcomes (Table 3). Methodologies for resilience training include face-to-face didactic sessions that use lectures, discussion groups, simulation, and out-of-class activities (Sanderson & Brewer, 2017). Resilience training provides opportunities for students to engage in self-assessment of resilience attributes, experiences, and situations that pose threats to resilience or trigger maladaptation. Resilience training may be offered as an elective course, workshop/seminar, or integrated into the curriculum, and should include self-assessment. An elective class or seminar course in resilience would help students devote more time to building protective factors that enhance resilience. A study by Li, Cao, Cao, and Liu (2015) suggests emotional intelligence interventions introduced in nursing curricula may increase emotional coping resources and social skills, which may benefit nursing student resilience and long-term occupational health. In a pilot study of nursing students enrolled in a mental health nursing course, Boardman (2016) implemented techniques building on self-efficacy and self-regulation, using interventions such as guided meditation, mindfulness walks, exercise, aromatherapy, reflective journaling, positive affirmations, and progressive muscle relaxation. Outcome measures indicated improved scores for resilience, increased mindfulness, and decreased stress. In a qualitative study to address high stress levels and mental health problems in first-year nursing students, van der Riet, Rossiter, Kirby, Dluzewska, and Harmon (2015) implemented a 7-week stress management and mindfulness program. Three main themes characterizing participants' experience were attending to self, attending to others, and attending to program-related challenges. Students reported improved sleep, concentration, clarity of thought, and fewer negative thoughts (van der Riet et al., 2015).

Elements for Resilience Enhancement and Training in Nursing Studentsa

Table 3:

Elements for Resilience Enhancement and Training in Nursing Students

One intervention that has shown promise for reducing stress and improving resiliency is the Stress Management and Resiliency Training (SMART) program (Chesak et al., 2015). The program was designed to help participants understand the neuroscience and biology of stress and learn skills to develop intentional attention and reframe life experiences using the five core principles of gratitude, compassion, acceptance, forgiveness, and higher meaning. Integrating the SMART program within the nursing program for students has the potential to decrease stress and anxiety and enhance resilience (Chesak et al., 2015). In a quasi-experimental study, Jameson (2014) found that a hardiness intervention had a significant effect on stress level in junior nursing students.

The quality of nurse educator relationships with nursing students can influence student resilience (Hurlington, 2010). In a synthesis of the nursing education literature on resilience, McAllister and McKinnon (2009) suggest that the ideal educational environment for supporting resilience is one that establishes effective social connections with peers, other adults, and faculty, and incorporates positive faculty role modeling and coaching techniques. In a qualitative study performed in university programs in South Africa, Froneman et al. (2016) applied the World Café data collection method to learn about the basic elements of effective educator–student relationships to strengthen resilience. Analyses yielded five main themes: (a) teaching/learning environment, (b) educator–student interaction, (c) educator qualities, (d) staying resilient, and (e) strategies to strengthen resilience. Students conveyed that they need interaction that is constructive, which included that the educator be approachable, respectful, friendly, professional, civil, adaptable, and nonthreatening, and must be patient with students who learn at different paces (Froneman et al., 2016). Educators are also responsible for creating a positive physical environment that includes an uncluttered classroom with fresh air; comfort breaks; fun activities during and between lessons; and an open, interactive, collaborative, and non-discriminatory emotional environment (Froneman et al., 2016). Scheduling major assignments and examinations to minimize concurrent deadlines will help minimize spikes in student stress levels. Nurse educators can emphasize skills that focus on deployment of personal and social resources in solving problems and sustaining stamina for nursing student resilience. Nurse educators can also foster student–peer relationship building through curriculum design that guides students in small group learning and encourages them to share opinions, praise, and constructive feedback (Zhao et al., 2016).

Structured experiential learning may enhance the competencies associated with resilience. Case studies, role plays, and simulation experiences can be used to improve emotional regulation, reflective ability, emotional intelligence, and empathy (Boardman, 2016; Foster & McKenzie, 2012). Educators provide structure and guidance in these learning activities to facilitate cooperative learning, problem solving, and social competence, and a sense of purpose and accomplishment. Chen (2011) articulates a methodology for implementing problem-based learning to build nursing student resilience through engagement with a realistic problem or situation with guided activities that promote self-efficacy in succeeding at challenging tasks, motivation to accomplish a goal, optimism about succeeding now and in the future, and self-reflection. Pines et al. (2014) designed a series of didactic and simulated training exercises delivered in four modules over two semesters to increase nursing students' perception of resiliency, empowerment, and conflict management.

The popular use of social media among younger students is a potential source of communication, mutual support, peer learning, and mentorship to enhance resilience (McAllister & Lowe, 2011). Sigalit et al. (2017) used social networking as a learning tool to enhance social ties and promote individual and group resilience among nursing students. Nurse educators can use social media technologies to develop a structured and organized support system for students that can be valuable during the nursing program and beyond (Sigalit et al., 2017). Nurse educators can use these teaching and learning strategies described above, recognizing that exposure to real-life circumstances and situations will help improve future response and activation of protective factors that promote resilience.

Limitations

The scope of the current study was limited in terms of design and the small convenience sample; thus, interpretation of findings must be considered with caution. The sample included nursing students in their last semester of nursing school, and their level of resilience may be different from that of nursing students just beginning the nursing program. The online survey was open for a brief period at the end of the semester when students were completing assignments and final examinations, which likely affected the low response rate. Response bias was also possible as the instruments used in the study comprised self-report measures, and students who responded may have significantly differed from those who did not respond. In addition, the study should be replicated in nursing student populations. Despite these limitations, the study provides support for the relevance and importance of resilience in nursing education. Further research is needed using large diverse samples and other biopsychosocial variables.

Conclusion

Nursing students face many unique stressors during their education program and it is paramount for them to develop resilience to buffer the effects of stress and facilitate adaptation to adversities. Only one third of participants in the current study scored as resilient on the CD-RISC-25. These findings suggest that nursing students are at risk for impaired resilience; students who have previously earned a college or university degree may be especially vulnerable to impaired resilience, as these students typically are older with more complex family and employment obligations in addition to academic demands. It is imperative to continue to develop an understanding of resilience so that the knowledge can be applied in nursing education. Findings from the current study add to growing evidence to support a focus on resilience in undergraduate nursing education.

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Sociodemographic Characteristics of Nursing Students (N = 27)

Variablen (%)
Gender
  Female22 (81)
  Male5 (19)
Age (years)
  ≤228 (30)
  23 to 3012 (44)
  ≥317 (26)
Race/ethnicity
  Caucasian16 (59)
  African American6 (22)
  Asian4 (15)
  Hispanic/Latino1 (4)
Relationship status
  Married13 (48)
  Single12 (44)
  Separate/divorced2 (7)
Has children7 (26)
Prior college or university degree13 (48)
Current/past work as a CNA21 (78)
Marriage or divorce in the past 1 year2 (7)
Extreme financial hardship in the past 1 year13 (48)
Death of a relative or friend in the past 1 year8 (30)
Mean (SD, Range)
CD-RISC-25a score73.26 (10.7, 45 to 96)
CD-RISC-10b score28.63 (5.09, 19 to 40)

Multiple Linear Regression Analysis of Connor-Davidson Resilience Scale-25 Scores (N = 27)

VariableB [95% CI]SEβtp Value
Married or partnered3.955 [–3.318, 11.23]3.5160.1881.1250.272
Have you earned another college or university degree?−7.890 [ −15.037, −0.743]3.455−0.375−2.2840.032
Have you experienced the death of a close friend or family member in the past 1 year?7.810 [−0.388, 16.007]3.9630.3401.9710.061

Elements for Resilience Enhancement and Training in Nursing Studentsa

Personal Resources/Protective FactorsContextual ResourcesStrategiesOutcomes
Adaptability/flexibility Conscientiousness Emotional intelligence Self-awareness Self-esteem, sense of personal worthiness Spirituality Sense of control Motivation Confidence Tenacity/persistence Sense of humor Ability to have close relationships Ability to manage range of emotions Delays gratification Desires to improve Communicates effectivelyLeisure/physical activity Mentorship Social and family support Peer support Faculty support Financial support Organizational cultureWork/life balance Meaning-making Problem solving Reflection Coping Self-careConnectedness Retention Satisfaction Well-being Employability

Studies on Resilience in Nursing Students using the CD-RISC-10 (N = 8)

Citation 1st author, yearAimMethodSampleCD-RISCKey findings
Aloba et al., 2016To explore psychometric characteristics of the 10-item CD-RISC in relation to self-esteem, depression, religiosity, and psychological distress among student nurses in southwestern NigeriaDescriptive cross-sectional study449 nursing students, M= 20.29 years (SD, 2.38), 87.5% femaleM=27.64 (SD, 6.44), range 9–40Scale has satisfactory reliability and construct validity, Cronbach's alpha 0.81; Factor analysis indicated resilience was explained by a two-factor model, labeled “toughness” and “motivation”.
Chamberlain et al., 2016To observe the predictors of resilience in third year nursing students as a strategy for dealing with or managing study and workplace related stress, and specifically assessed, innate dispositional mindfulness, professional quality of life, and employmentObservation al quantitative successive independent samples survey design240 3rd year undergrad uate nursing students from three Australian universitie s; M=29 years (SD, 10.56), years, 89% femaleM=37.0 (SD, 7); males M=30.09; females M=27.29 (p=.003)In stepwise linear regression, dispositional mindfulness subset acceptance made strongest contribution, followed by expectation of graduate nurse transition program acceptance; predictive model explained 57% of the variance in resilience.
Chow et al., 2018To explore the relationship between resilience and well-being in nursing students in relation to academic successDescriptive cross-sectional study678 university undergrad uate and graduate nursing students in Hong Kong; 89% female, age not reportedM=24.0 (SD, 5.7), range, 7–40Senior students had significantly higher level of perceived well-being than junior students; Multivariable regression analysis found that resilience was significant predictor of perceived well-being.
Kong et al., 2016To examine positive associations between emotional intelligence and clinical communication ability among practice nursing students and to determine whether resilience plays a moderating role in the relationshipDescriptive cross-sectional study377 graduate students in nursing who were interns in the hospital, 81.7% female, M= 21.36 years (SD, 1.24), range, 16–24Chinese version; M=28.2 (SD, 5.61)Emotional intelligence was positively associated with clinical communication ability; Resilience significantly affected clinical communication ability and moderated relationship between emotional intelligence and clinical communication ability.
Li et al., 2015To investigate the relationships among post-traumatic growth, emotional intelligence and psychological resilience in vocational nursing students who have experienced childhood adversitiesDescriptive cross-sectional study202 Chinese vocational school nursing students, all female, M=19.4 years (SD, 0.8), range, 18–22 yearsChinese version; M=23.96 (SD, 6.56)A curvilinear relationship between emotional intelligence and post-traumatic growth, and between psychological resilience and post-traumatic growth; Moderate-level emotional intelligence and psychological resilience were most associated with the greatest levels of growth.
Mathad et al., 2017To identify correlates and predictors of resilience among nursing studentsDescriptive correlational study194 1st to four levels of nursing students in colleges of nursing, India, 94% female, 99% single, age not reportedM= 26.31 (SD, 6.28) range 5–40Students moderately resilient; Resilience significantly correlated with mindfulness, perseverative thinking and empathy in nursing students.
Ríos-Risquez et al., 2016To examine relationship between resilience, academic burnout and psychological health in a sample of nursing studentsDescriptive cross sectional study113 nursing students in final academic year of university; 75.2% female, M=24.42 years (SD=5.27) ,Spanish, M=34.70 (SD, 4.82)Resilience was associated with lower levels of psychological discomfort and academic burnout; Analysis indicated that high resilience scores and low emotional exhaustion scores predict better perceived psychological health.
Sigalit et al., 2017To explore the associations between students' personal and group resilience to their utilization of social networking platforms and formally taught communication skills, students personal and clinical characteristics related to resilience, and factors that contribute to satisfaction with clinical placementDescriptive cross-sectional study149 second year university nursing students in Israel; 89% female, most single, M= 22.7 years (SD, 2.61)10-item, M=2.93 (SD, 0.06)Positive correlations between students' use of social networking to their personal and group resilience; Social media use, religion, and clinical placement were related to resilience and perceived helpfulness of the communication course. Social networking can be used to promote resilience.
Authors

Dr. Lekan is Assistant Professor, University of North Carolina at Greensboro School of Nursing; Dr. Ward is Associate Dean, College of Health and Human Sciences, and Director, School of Nursing, North Carolina Agricultural and Technical State University; and Ms. Elliott is Staff Nurse, Moses H. Cone Hospital, Greensboro, North Carolina.

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

The authors thank Susan Letvak, PhD, RN, FAAN, for review of the manuscript; Thomas P. McCoy, PhD, PStat, and Alia Henderson, BS, for assistance with data analysis; and Peggy Markham, BA, MS, MSLS, for editorial assistance.

Address correspondence to Deborah A. Lekan, PhD, RN-BC, Assistant Professor, University of North Carolina at Greensboro, School of Nursing, 409 Moore Nursing Building, Greensboro, NC 27402-6107; e-mail: dalekan@uncg.edu.

Received: January 26, 2018
Accepted: April 03, 2018

10.3928/02793695-20180619-06

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