Journal of Nursing Management, 2014, 22, 720–734

Resilience in nurses: an integrative review

PATRICIA L. HART P h D , R N 1, JANE D. BRANNAN E d D , R N 2 and MARY DE CHESNAY D S N , P M H C N S - B C , F A A N 2

1
Assistant Professor of Nursing, and 2Professor of Nursing, Kennesaw State University, WellStar School of
Nursing, Kennesaw, GA, USA

Correspondence HART P.L., BRANNAN J.D. & DE CHESNAY M.(2014) Journal of Nursing Management
Patricia L. Hart 22, 720–734.
Kennesaw State University Resilience in nurses: an integrative review
WellStar School of Nursing
1000 Chastain Road Aim To describe nursing research that has been conducted to understand the
Kennesaw phenomenon of resilience in nurses.
GA 30144 Background Resilience is the ability to bounce back or cope successfully despite
USA adverse circumstances. Nurses deal with modern-day problems that affect their
E-mail: [email protected]
abilities to remain resilient. Nursing administrators/managers need to look for
solutions not only to recruit nurses, but to become knowledgeable about how to
support and retain nurses.
Evaluation A comprehensive search was undertaken for nursing research
conducted between 1990 and 2011. Key search terms were nurse, resilience,
resiliency and resilient. Whittemore and Knafl’s integrative approach was used to
conduct the methodological review.
Key issues Challenging workplaces, psychological emptiness, diminishing inner
balance and a sense of dissonance are contributing factors for resilience.
Examples of intrapersonal characteristics include hope, self-efficacy and coping.
Cognitive reframing, toughening up, grounding connections, work-life balance
and reconciliation are resilience building strategies.
Conclusion This review provides information about the concept of resilience.
Becoming aware of contributing factors to the need for resilience and successful
strategies to build resilience can help in recruiting and retaining nurses.
Implications for nursing management Understanding the concept of resilience can
assist in providing support and developing programmes to help nurses become
and stay resilient.
Keywords: integrative review, nurse, resilience, resiliency, resilient

Accepted for publication: 16 July 2012

the varied definitions of resilience is strength and peo-

Introduction
ple who are described as resilient are said to be able
Resilience is the ability of individuals to bounce back to persist in overcoming challenging obstacles.
or to cope successfully despite adverse circumstances Nursing administrators/managers are faced with the
(Rutter 2008). Resilience has been referred to as a per- challenges to recruit and retain nurses within their
sonality trait (Fredrickson et al. 2003, Campbell-Sills healthcare organisations. In today’s world, the short-
et al. 2006) and a dynamic process (Luthar 2006). age of nurses is a global issue. The shortage is based
Resilience is used to describe when a person recovers on two factors: a decreased supply and an increased
easily and quickly from setbacks that occur during his demand for nurses (Oulton 2006). The World Health
or her life (Zautra et al. 2010). A common theme in Organisation (WHO) (2006) estimates a global deficit

DOI: 10.1111/j.1365-2834.2012.01485.x
720 ª 2012 John Wiley & Sons Ltd
 Resilience in nurses

of 2.4 million doctors, nurses and midwives in 57 patient outcomes (Roberts et al. 2009, Roche et al.
countries with nurses representing the largest percent- 2010). For example, nurses have felt under pressure
age of the deficit. The nursing shortage and costs for from administration to be gap-fillers and they have
nursing turnover affects developed and developing routinely pitched in to help out when needed to ensure
countries. In 2010, the national hospital average turn- patient safety. As nurses became more educated, they
over rate in the United States (USA) was 14.6% with learned to speak up and demand more support from
an average turnover rate for bedside nurses at 13.8% administrators to meet the demands of their jobs. The
(Nursing Solutions Inc 2011). Costs of nurse turnover old doctor–nurse game has been replaced with a more
are estimated from $22 000 to over $64 000 in the collegial atmosphere in hospitals (Schmalenberg &
USA per nurse (Stone et al. 2003, Waldman et al. Kramer 2009) and new human resource policies have
2004, Jones 2005, O’Brien-Pallas et al. 2006). In Can- been implemented to protect workers. However,
ada, nurse turnover rates in hospitals average 20% nurses still face more modern problems such as nurs-
with an estimated cost of approximately $25 000 and ing shortages, higher patient acuity, proliferation of
a projected deficit of 60 000 nurses by the year 2022 new technology, regulatory requirements, physical and
(Tomblin Murphy et al. 2009). Oulton (2006) psychological demands, and ethical dilemmas. Despite
reported statistics gathered from The International economic hardships, challenges in the workplace and
Council of Nurses in 2003 indicating that Europe, modern issues, nurses continue to serve the public and
Germany and the Netherlands had a deficit of 13 000 to do extraordinary work with few resources, but the
nurses, Switzerland estimated a shortage of 3000 nurses stress of the job creates challenges for the retention of
and France had an exodus of about 18 000 nurses from nurses. If experienced nurses have difficulty coping
public hospitals each year. In Jamaica, approximately with today’s pressures, new graduates are even more
8% of nurses and 20% of specialty nurses leave at risk for burnout. Nursing administrators/managers
annually (Lowell et al. 2004). In developing countries need to look for solutions not only to recruit nurses to
such as Ghana, Zimbabwe, Malawi and Uganda the their healthcare organisations but more importantly to
shortage is at a critical level due in part to migration become knowledgeable about how to support and
of nurses within those countries who are seeking retain nurses once they are employed.
better working conditions (Buchan & Dovlo 2004, In this paper, the authors provide current knowledge
Dugger 2004). Because of the nursing shortage and on the concept of resilience in the hope of suggesting
vacancies of nurses, nursing administrators/managers strategies for nursing administrators/managers to
deal with budget issues related to costs for advertise- strengthen the nursing workforce. Though concept
ment and recruitment, hiring, orientation and train- analyses on resilience (Olsson et al. 2003, Shin et al.
ing, paying of agency nurses and overtime. In 2009) and literature reviews (Mackay 2003, Agaibi &
addition, research supports that nurse staffing levels Wilson 2005) about other populations have been con-
and nurse turnover affect patient outcomes and the ducted, there has been minimal attention to applying
quality of patient care (Aiken et al. 2002, Lankshear the concept to transition to practice and to the reten-
et al. 2005, Kane et al. 2007). tion of experienced nurses. Therefore, this integrative
A group not generally considered a vulnerable popu- review examined the phenomenon of resilience in the
lation in the health disparities literature is nurses; yet nursing profession. The findings may guide nursing
the high degree of job stress of new graduates and administrators/managers to develop new programmes
experienced nurses in today’s healthcare climate has and support systems to help new graduates and to
resulted in high turnover with concurrent expenses retain experienced nurses. Additionally, the findings
related to recruiting and orienting replacements (Casey may direct future research in delineating the concept
et al. 2004, O’Brien-Pallas et al. 2006, Nursing Solu- of resilience in nursing practice where effective strate-
tions Inc 2011). There are a variety of occupational gies to build resilience in nurses can be developed.
challenges affecting nurses including making mistakes
due to understaffing, poor support, high acuity and
Prior conceptual work
long hours (Rogers et al. 2004, Dunton et al. 2007,
Kane et al. 2007). The organisational culture for Several concept analyses (Dyer & McGuinness 1996,
many nurses includes violence in the workplace from Earvolino-Ramirez 2007, Gillespie et al. 2007a) on
patients and families, disruptive behaviours (abuse, resilience have been published as nursing scholars
bullying and horizontal violence) from healthcare have realized the relevance of the concept to clinical
colleagues and sexual harassment that may impact practice. Dyer and McGuinness (1996) identified

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Journal of Nursing Management, 2014, 22, 720–734 721
P. L. Hart et al.

rebounding and carrying on, a sense of self, determi- & Knafl 2005). The focus of this integrative review
nation and a prosocial attitude as critical attributes of was to provide information on what nursing popula-
resilient individuals. Ten years later, Earvolino- tions have been studied, identify contributing factors
Ramirez (2007) identified similar attributes such as to the need for resilience, discover characteristics of
rebounding/reintegration, high expectancy/self-deter- nurses that promote resilience, and ascertain strategies
mination, positive relationships/social support, flexibil- that help build resilience in nurses. Therefore the fol-
ity, sense of humour and self-esteem/self-efficacy. lowing research questions guided this review:
Additionally, Gillespie et al. (2007a) identified self-
 What nursing populations have been studied regard-
efficacy, hope and coping as defining attributes of
ing resilience and are they representative of diverse
resilience. Antecedents of resilience have been identi-
populations of nurses?
fied as adversity (Dyer & McGuinness 1996, Earvolino-
 What factors contribute to the need for resilience in
Ramirez 2007, Gillespie et al. 2007a), physically and/
the nursing profession?
or psychologically traumatic situation (Gillespie et al.
 What intrapersonal characteristics are associated
2007a), intellectual capacity to interpret adversity
with resilience behaviour in nurses?
both cognitively and socially (Gillespie et al. 2007a),
 What strategies do nurses participate in to build
having a realistic world view (Gillespie et al. 2007a)
personal resilience in the nursing profession?
and the presence of a caring individual in the person’s
life at some point in time (Dyer & McGuinness Additionally, the intent was to gain knowledge that
1996). Effective coping (Dyer & McGuinness 1996, will help nurses and nursing administrators/managers
Earvolino-Ramirez 2007), mastery or personal control learn how to enhance and improve resilience while
(Dyer & McGuinness 1996, Earvolino-Ramirez 2007, working in the profession of nursing. Conducting such
Gillespie et al. 2007a), positive adaptation or adjust- an integrative review synthesizes current nursing
ment (Earvolino-Ramirez 2007, Gillespie et al. 2007a) research in the area of resilience in nursing practice
and personal growth (Gillespie et al. 2007a) were and identifies gaps in the literature to focus future
identified as consequences of resilience. research.

Scope of the review Data search stage

The authors conducted an integrative review of pub- The second stage of the review process is the litera-
lished literature related to resilience in nurses. A meth- ture search stage that details the strategies used to
odological review using an integrative approach based obtain the relevant literature on the topic of interest
on Whittemore and Knafl (2005) was used to search (Whittemore & Knafl 2005). The data search (collec-
the literature for studies focused on the concept. This tion) stage was conducted during 2011 and finalized
approach permitted the inclusion of studies using a the first 2 weeks of January 2012 to be sure that
variety of research designs, specifically, experimental articles published at the end of 2011 were included.
and non-experimental research more fully to under- During this stage, searches were conducted using the
stand the concept of resilience in nursing. Whittemore following electronic databases: (i) Cumulative Index
and Knafl’s (2005) integrative approach framework to Nursing and Allied Health Literature (CINAHL),
consists of five stages (problem identification, litera- (ii) Medline, (iii) EBSCO host and (iv) Proquest. Key
ture search, data evaluation, data analysis and presen- search terms were nurse, resilience, resiliency and
tation) to enhance the rigour of the process when resilient. Publications were included if (i) the topic
conducting an integrative review. Empirical literature addressed resilience in nursing, (ii) participants in the
on resilience in nursing was summarized and analysed studies were nurses, (iii) the design was either quali-
based on this integrative framework to draw an over- tative or quantitative, (iv) language was English, and
all conclusion about what is known about the phe- (v) date of publication was between January 1990
nomenon of resilience in professional nursing practice. and December 2011. The rationale for focusing on
literature after January 1990 and forward was to
review the literature that best represented the modern
Problem identification stage
day issues nurses face such as nursing shortages,
The problem identification stage involves delineating a higher patient acuity, proliferation of new technology,
clear picture of the problem that the review is addressing regulatory requirements, physical and psychological
and outlining the purpose of the review (Whittemore demands, and ethical dilemmas. Publications were

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722 Journal of Nursing Management, 2014, 22, 720–734
 Resilience in nurses

excluded if (i) they were not published (e.g. disserta- worked independently to review the titles and
tions and theses), (ii) they were written in other lan- abstracts then proceeded to an extensive reading of
guages, (iii) participants were non nurses or from each publication to ensure that the content focused on
other health disciplines, and (iv) they were not resilience in nursing. Publications meeting the inclu-
empirical research studies (discussion and review sion criteria were then thoroughly reviewed in depth.
papers). The seven articles were then evaluated for quality
A total of 462 articles were identified in the initial using either a quantitative or qualitative critical
search using the search terms. Each abstract was appraisal tool (Law et al. 1998, 2007). Review criteria
reviewed to determine if the publication met the inclu- for quantitative studies included study purpose,
sion criteria. The majority of research publications design, sample size, outcomes, interventions, results,
were completed on populations other than nurses conclusions and implications. Review criteria for qual-
resulting in 455 articles being eliminated. Seven itative studies included study purpose, qualitative
abstracts (Simoni et al. 2004, Ablett & Jones 2007, design, sampling framework, data collection methods
Gillespie et al. 2007b, 2009, Hodges et al. 2008, and data analysis. To increase the reliability of the
Glass 2009, Kornhaber & Wilson 2011) met the review, the articles and completed forms were
inclusion criteria and the studies were retrieved and reviewed by the other two authors independently.
reviewed. Ancestry review of the reference lists was Then, all three authors met together on several occa-
conducted to search for additional publications meet- sions to review the critical appraisal forms and partici-
ing the inclusion criteria. No other publications were pated in the critique and summarization of each
identified from the ancestry review. Figure 1 details article. When ambiguities occurred regarding the criti-
the data search (collection) process. cal appraisal review, all three authors discussed the
concerns until an agreement was reached.
Additionally, each study was ranked on the level of
Data evaluation stage
evidence using a 7-level scale ranging from Level 1
The data evaluation stage entails evaluating the qual- [systematic review or meta-analysis of randomized
ity of the primary sources using a methodological controlled trials (RCT), or evidence-based clinical
approach that consists of using quality criteria apprai- practice guidelines based on systematic reviews of
sal tools in the evaluation process (Whittemore & RCTs] to Level VII (opinion of authorities and/or
Knafl 2005). For this review, the first author initially reports of expert committees) (Melnyk & Fineout-
Overholt 2005). All seven articles were ranked at a
Level VI (single descriptive/qualitative/physiological
study). Despite some methodological limitations
Potentially relevant publications by
literature search (addressed in the limitation section) and the low level
n = 462
of evidence, all seven articles (Simoni et al. 2004,
Ablett & Jones 2007, Gillespie et al. 2007b, 2009,
Publications exclude after
evaluation of abstract Hodges et al. 2008, Glass 2009, Kornhaber & Wilson
n = 455
2011) were included in the review due to the paucity
Publications retrieved for detailed of research in this area.
examination
n=7
Of the seven studies, three were quantitative
(Simoni et al. 2004, Gillespie et al. 2007b, 2009) and
Publications excluded after four were qualitative (Ablett & Jones 2007, Hodges
review of full paper
n=0 et al. 2008, Glass 2009, Kornhaber & Wilson 2011).
The quantitative studies included two predictive
Publications assessed for research designs and one correlation, cross-sectional
methodological quality
n=7 research design. The qualitative studies included three
phenomenology research designs and one ethnogra-
phy research design. Four of the studies originated
Publications included in the from Australia (Gillespie et al. 2007b, 2009, Glass
integrative review
n=7 2009, Kornhaber & Wilson 2011), two from the Uni-
ted States (Simoni et al. 2004, Hodges et al. 2008)
Figure 1 and one from the United Kingdom (Ablett & Jones
Data search (collection) process. 2007).

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Journal of Nursing Management, 2014, 22, 720–734 723
P. L. Hart et al.

Data analysis stage two studies reported the ethnicity/race of the partici-
pants which were majority Caucasian (Simoni et al.
During the data analysis review, data from the pri-
2004, Hodges et al. 2008). The other five studies did
mary sources are organised, categorized and summa-
not report ethnicity/race of their study participants
rized into an integrated conclusion about the research
(Ablett & Jones 2007, Gillespie et al. 2007b, 2009,
problem under study (Whittemore & Knafl 2005). In
Glass 2009, Kornhaber & Wilson 2011).
this review, a matrix was developed that outlined
Practice settings where the participants were
(i) the population being studied, (ii) contributing fac-
recruited varied greatly among the studies. Three
tors for the need of resilience, (iii) characteristics of
included participants from hospitals (Simoni et al.
nurses that promote resilience and (iv) strategies that
2004, Hodges et al. 2008, Kornhaber & Wilson
help to build resilience in nurses. Content from the
2011). Gillespie et al. (2007b, 2009) enrolled partici-
articles were then extracted populating the matrix.
pants who were members of the Australian College of
The results were then integrated and analysed using a
Operating Room [OR] Nurses. Nurses working in a
constant comparative method to organise and catego-
hospice setting were the informants in the Ablett and
rize the data.
Jones (2007) study. One study recruited participants
working in academia (Glass 2009).
Review presentation stage
The final stage in the integrative review process is the Contributing factors
data presentation. Researchers provide the readers Challenging workplaces, psychological emptiness,
with explicit details from each of the primary sources diminishing inner balance and a sense of dissonance in
to exhibit evidence in support of the final conclusions the workplace are key contributing factors that affect
from the review (Whittemore & Knafl 2005). In this resilience in professional nursing practice (Hodges
review, studies were synthesized under the following et al. 2008, Glass 2009, Kornhaber & Wilson 2011).
subheadings: author, date of publication, country, Challenging workplaces that are constantly changing
study design, sample population and findings and very demanding on nurses affect their ability to
(Table 1). Synthesizing the information from each be resilient in academic and healthcare environments.
study provided a final summarization of the findings Organisational goals that are not congruent with
about what is known about resilience in professional nurses’ professional or personal goals cause conflict
nursing. within themselves when practising.
Psychological emptiness results from frustrations
that happened in the workplace. These events left
Results nurses feeling ‘stripped down’ and unable to reconcile
their beliefs and emotions. Nurses viewing their work-
Research populations
places as not caring about them personally or not val-
Demographic characteristics including gender, age, uing their opinions were eventually depleted of their
and ethnicity/race varied among the studies. In the psychological reserves (Glass 2009).
majority of the studies, 90% of the participants were Diminished inner balance was demonstrated when
female (Ablett & Jones 2007, Gillespie et al. 2007b, nurses were unable to balance the demands of work
2009, Hodges et al. 2008, Glass 2009). Two studies with their outside lives (Glass 2009). Nurses who
had a 100% sample of female participants (Simoni were not able to put work and personal life demands
et al. 2004, Kornhaber & Wilson 2011). Only a small in perspective were more susceptible to ‘burnout’ in
representation of male nurses was included in the their profession.
seven studies. One study reported the age range Dissonance in the workplace results in feelings of
(25–58) of participants along with the mean age anxiety and ambiguity for new graduates. New gradu-
(38.4) (Kornhaber & Wilson 2011). In two studies, ate nurses struggle with the difference between their
only the age range of participants (23–60 years) were academic preparation and the real world of nursing
reported (Hodges et al. 2008, Glass 2009). Two studies practice. The practice gaps between the academic set-
only reported the mean age (46.1 and 35.4, respec- ting and actual nursing practice within a healthcare
tively) of the participants (Simoni et al. 2004, Gillespie organisation resulted in new graduate nurses becom-
et al. 2009) and two studies did not report the ages at ing frustrated with their work environment (Hodges
all (Ablett & Jones 2007, Gillespie et al. 2007b). Only et al. 2008).

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 Resilience in nurses

Table 1
Summary of findings from research studies

Author/year/country Design Sample population Findings (excerpts from articles)

Ablett and Jones Qualitative, 10 nurses (nine female 10 themes related to the concepts
(2007) (UK) Phenomenology and one male) of hardiness and sense of
Race: not reported coherence
Age: not reported  An active choice
Education: not reported  Past personal experiences
Years of practice:  Personal attitude to caregiving
not reported  Awareness of spiritually
Setting: Palliative care  Personal attitudes to work
nurses working in hospice  Aspects of job satisfaction
 Aspects of job stress
 Personal attitude to life and death
 Ways of coping
 Personal/professional issues and
boundaries
The findings illustrate the
interpersonal factors that may
enable hospice workers to remain
resilient and effectively buffer
or moderate the stressful effects
of working in palliative care
Gillespie et al. Quantitative, 772 nurses (91.6% female) Hope, self-efficacy, coping, control
(2007b) Correlational-cross Race: not reported and competence explained 60%
(Australia) sectional Age: not reported of the variance in resilience
Instrument: Connor-Davidson Education: Hope was the strongest unique
resilience scale: 25 items Hospital certificate: 71.6% contributor to resilience
rated on a 5-point Likert Associate: 2.8% Age, experience, education and
response format (0 = not Degree: 40.3% years of employment were not
all true to 4 = true nearly Master’s: 7.8% statistically significant in explaining
all the time) Doctorate: 0.3% resilience in OR nurses
Years of practice: not
reported
Setting: Australian College of
Operating Room Nurses
(ACORN)
Gillespie et al. Quantitative, Predictive 735 nurses (94% female) Modest statistically significant
(2009) Instrument: Connor-Davidson Race: not reported associations between age and years of
(Australia) resilience scale: 25 items Age: Mean: 46.1 OR experience and
rated on a 5-point Likert Education: resilience
response format (0 = not Hospital certificate: 73.4% No relationship between education
all true to 4 = true Diploma: 3.0% and resilience
nearly all the time) Degree: 42.8% Year of OR experience only predicted
Postgraduate certificate: 52.8% 3.1% of the variance in resilience
Postgraduate diploma: 20.6 Large proportion of variance in
Master’s: 8.2% resilience remains unexplained,
Doctorate: 0.3% suggestive that other variables
Years of practice: Average years are associated with resilience
of OR experience:17.8 years
Setting: Nurses who were
members of the Australian
College of operating
Room Nurses (ACORN)
Glass (2009) Qualitative, Ethnography 20 nurses (18 females and Challenging workplaces, psychological
(Australia) two males) Race: not reported emptiness, and diminishing inner
Age: (32–60 years) balance are contributing factors
Education: for the need of resilience and
PhD qualified: 12 restoration of inner healing
PhD submission within 12 Flexibility, adaptability and emotional
months: 3 Planning to enrol intelligence were identified as
in PhD: 2 No intention of components of resilience
enrolling in PhD: 3 Cognitive reframing and grounding
Years of practice (in academic setting): are strategies to sustaining resilience
Fewer than 5 years: 2 in the workplace

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P. L. Hart et al.

Table 1
(Continued)

Author/year/country Design Sample population Findings (excerpts from articles)

5–10 years: 2 Hope, optimism and resilience

More than 10 years: 15 united are a powerful healing
Setting: Schools of nursing in public force to combat and/or minimize
universities workplace challenges
Hodges et al. Qualitative, Phenomenology 11 nurses (10 female and one male) Three themes and subthemes for
(2008) (USA) Race: developing professional resilience
Caucasian: 9 in practice:
African American: 2 Learning the Milieu
Age: 23–31 Learning the culture (people, formal,
Education: Baccalaureate: 100% and informal rules
Years of practice: 12–18 months Learning RN skill sets (techniques,
Setting: Southeastern city in USA time mgt, and pace)
Practice areas: Labor and delivery, Discerning Fit
mother–baby, emergency department, Sensing discrepancies
neonatal intensive care, medical adult Reconciliation of one’s identity as a
care, telemetry professional nurse
Moving through
Turning point
Street smarts
Critical reflection and reconciliation
were strategies used
for resilience
Kornhaber and Qualitative, phenomenology Seven nurses (100% female) Six categories identified
Wilson (2011) Race: not reported Toughening up
(Australia) Age: 25–58, mean 38.4 Natural selection
Education: Emotional toughness
Baccalaureate: 5 Coping with the challenges
Hospital qualified: 2 Regrouping and recharging
Years of practice (in burns nursing): Emotional detachment
3–23 years, mean: 11.4
Setting: Large, acute care,
public hospital
Practice area: Burns unit
Simoni et al. Quantitative, Predictive 142 nurses (100% female) 24% of the variance of psychological
(2004) (USA) Instrument: Stress resiliency Race: 99.3% Caucasian empowerment was explained by the
profile: 18-items rated on a Age: Mean: 35.4 interpretative styles of stress
7-point Likert response Education: resiliency, skill recognition
format (1 = strongly disagree Baccalaureate: 47.7% (20% of variance) and deficiency focusing
to 7 = strongly agree) Associate: 40.9% (4% of variance).
Diploma: 12% Nurses who believe they are effective
Years of practice: in caring for patients (skill
Fewer than 5 years: 42% recognition) and who did not
5–10 years: 23% visualize their own failure (deficiency
More than 10 years: 35% focusing) were more psychologically
Setting: two hospitals in empowered which provided
Mid-Atlantic state; four resilience to endure the stresses
nursing units – medical-surgical, within their workplace
intensive care step-down, paediatrics,
skilled nursing

Gillespie et al. (2009) found modest statistically sig-

Personal/intrapersonal characteristics nificant associations between age and years of experi-
Inconsistency exists whether personal characteristics ence and resilience in OR nurses. In a regression
of nurses such as age, experience, education and analysis only years of OR experience predicted resil-
years of employment contribute to the resilience in ience, but explained a small 3.1% of the variance.
nurses. In a study conducted by Gillespie et al. The authors concluded that resilience is not necessar-
(2007b) age, experience, education and years of ily dependent on nurses’ age, experience and educa-
employment did not contribute to resilience at statis- tion. Rather, resilience appears to be predicted by
tically significant levels. In a later study, however, other attributes.

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726 Journal of Nursing Management, 2014, 22, 720–734
 Resilience in nurses

Intrapersonal characteristics related to resilience in Kornhaber and Wilson (2011) found that burns unit
nurses included hope, self-efficacy, coping, control, nurses were toughened up just by the repeated expo-
competence, flexibility, adaptability, hardiness, sense sure of caring for patients with burns. Dealing with
of coherence, skill recognition and non-deficiency the physical changes and disfigurement on a daily
focusing (Simoni et al. 2004, Ablett & Jones 2007, basis enabled the nurses to approach their work
Gillespie et al. 2007b, Hodges et al. 2008). Hardiness through ‘hardened’ lenses to protect themselves
and a sense of coherence were found to be effective in emotionally.
hospice nurses in their ability to be resilient in a palli- Emotional toughness and emotional detachment
ative care environment (Ablett & Jones 2007). Hos- were identified as strategies that allowed nurses to
pice nurses buffered the stressful effects of working in perform nursing care in challenging and stressful
palliative care by having an active voice, relying on patient care situations. Emotional detachment allowed
past personal experiences, having attitudes of making nurses to perform painful, uncomfortable patient
a difference, being aware of their spirituality, main- procedures that were necessary in patients’ recovery
taining commitment towards their work, developing process. Developing an emotional toughness enabled
personal attitudes about life and death, and being able the nurses to perform their duties and to remain some-
to set personal and professional boundaries. what emotionally detached from their patients but
Hope, self-efficacy, coping, control and competence also focusing on the positive rather than negative
explained 60% of the variance in resilience of OR aspects of providing nursing care (Kornhaber & Wilson
nurses (Gillespie et al. 2007b). The strongest explana- 2011).
tory variables were hope, self-efficacy and coping, Grounding connections with family, friends and col-
with hope contributing the strongest variance. Fur- leagues is another approach nurses used to cope with
thermore, flexibility, adaptability and having emo- their work environments. Re-connecting to people
tional intelligence were found to be important with whom nurses had close relationships allowed
components in resilience (Glass 2009). Nurses who them to focus on their belief and value systems that
were hopeful and optimistic were able to combat or contributed to their ability to put workplace chal-
minimize the challenges in organisations and to main- lenges and stresses into perspective. Maintaining work
tain their resilience. –life balance was essential for nurses to build and
Additionally, new graduate nurses who were focused, maintain a sense of resilience (Ablett & Jones 2007,
goal oriented and capable of solving problems were Glass 2009).
found to demonstrate resilient behaviour (Hodges et al. According to findings by Hodges et al. (2008) new
2008). Nurses who held beliefs that they were effective graduate nurses engaged in critical reflection to assimi-
in caring for patients (skill recognition) and did not late their nursing education within the real world of
visualize their own failure (deficiency focusing) were nursing practice. Critical reflection provided a method
more psychologically empowered. These beliefs enabled for them to problem-solve and adapt to the realities of
them to endure the stresses within their workplace professional nursing practice (Hodges et al. 2008).
(Simoni et al. 2004). Additionally, reconciliation allowed nurses to reaf-
firm their commitment to the profession of nursing.
Reconciliation provided a mechanism for nurses to
Strategies for building resilience
find meaning in their work that is congruent with
Strategies used by nurses to build resilience included their beliefs and value systems (Hodges et al. 2008).
cognitive reframing, toughening up, emotional tough-
ness and emotional detachment, grounding connec-
Limitations
tions and work–life balance, critical reflection and
reconciliation (Ablett & Jones 2007, Gillespie et al. There were several methodological limitations to the
2007b, 2009, Kornhaber & Wilson 2011). Nurses studies. Some studies did not provide detailed
used cognitive reframing to review and retrace their information about the sample characteristics and sam-
internal and external environments enabling them to ples were not representative of diverse populations.
promote psychological flexibility and adaptability. The majority of participants in the studies were female
Cognitive reframing provided nurses with the ability with minimum representation from males. Only two
to re-vision or re-create their work environment into a studies reported ethnicity/race. The majority of partici-
more effective workplace (Hodges et al. 2008, Glass pants were Caucasian female. Ages of the participants
2009). were reported as ranges in two studies, mean age in

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P. L. Hart et al.

two studies, and the ages of participants were not Additionally, nurses who buffered their current situa-
reported at all in two studies. The limited information tion by considering the future and using coping mech-
describing the sample populations does not provide anisms to aid in ‘moving through’ (Hodges et al.
researchers with a clear picture of what populations 2008) were described as those who exhibited greater
have been included in the studies. resilience.
Additionally, a variety of practice settings were rep- There was evidence that developing and strengthen-
resented limiting the generalizability of the findings ing personal (individual) resilience was a key factor in
from the studies. Practice settings included hospital coping with a stressful work environment in nursing.
agencies, a professional organisation of OR nurses, a Learned behaviours that contribute to personal resil-
hospice agency and an academic setting. As each of ience were suggested as a direction for nursing educa-
these settings brings unique work environments to tion and in the workplace. Collegial support was a
nurses, nurses may face different challenges resulting significant factor identified in the review. Human
in different dimensions of resilient behaviours or strat- interactive aspects and connections was a major factor
egies to remain resilient within that setting. that contributed to the personal development of resil-
Research designs of the seven studies were primarily ience. Whether through reflective journaling (Hodges
surveys or qualitative interviews. Strong validity and et al. 2008), grounding connections with others and
reliability of each of the instruments and scales was balance (Ablett & Jones 2007, Glass 2009), or profes-
reported in the survey studies. Because of the variabil- sional networking relationships and collaboration
ity in the research questions and hypotheses (factors in (Gillespie et al. 2007b, 2009) the central factor is the
development of resilience, description of resilience, or supportive relationship.
levels of resilience that predict a sense of empower- In addition, other individual strategies that nurses
ment), the ability to infer specific methods for building can employ to build resilience include maintaining a
personal resilience is limited. However, the scales that positive attitude by engaging in humour, laughter,
were used in two studies (Gillespie et al. 2007b, positive thinking techniques, visualization techniques
2009) provide additional instrument validation and and positive reaffirmations (Jackson et al. 2007).
evidence of their usefulness for future research in mea- Engaging in extracurricular activities such as exercise,
suring resilience in nurses. volunteerism and social network groups provides an
avenue for stress reduction and refocusing on personal
fulfilment and goals (Brannan et al. 2011). Seeking
Discussion
out trusted mentors to provide guidance, motivation,
The development of resilient behaviour by nurses in emotional support and role modelling can assist nurses
response to an overwhelming workplace has been in exploring career goals, networking opportunities
associated with increased quality of life, better health and resources (McCloughen et al. 2009, Ferguson
and effective use of adaptive coping strategies (Gilles- 2011, Fowler 2011).
pie et al. 2007b, Glass 2009). Yet ongoing demands, While finding ways to improve resilience in nurses is
challenges, frustrations and anxieties that impact important, nursing administrators/managers can
nurses each day are often so overpowering that burn- greatly impact resilience in nurses by fostering a posi-
out frequently results. Nursing administrators/managers tive organisational culture in the workplace. Vulnera-
need strategies that can be implemented to support bility of nurses may be directly related to an adverse
and build resiliency in nurses. Table 2 provides an environment encountered in their workplace. Stress
outline of strategies to support and build resiliency and burnout continue to be factors in the rate of nurs-
within the nursing workforce at the individual, group ing position turnover in hospital environments (Baern-
and organisational level. holdt & Mark 2009). Nurses routinely work in high
Intrapersonal characteristics such as hardiness, self- stress and often complex areas doing their work with
efficacy or a sense of hope were identified as factors people who are suffering – a difficult situation under
that were components of resilience. A general feeling the best of circumstances. A lack of support and
of optimism and hopeful outlook were common char- resources, high patient acuity, lack of autonomy and
acteristics of the more resilient nurses. Nurses who complexity of the unit contribute even further to an
were able to recognize and identify their own situa- overwhelming and potentially adverse environment
tional concerns, reframe, adapt and look forward to a (Baernholdt & Mark 2009), and may lead to emo-
time when the current situation might be altered were tional exhaustion and burnout driving nurses to leave
typically associated with higher levels of resilience. the profession (American Association of Colleges of

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728 Journal of Nursing Management, 2014, 22, 720–734
 Resilience in nurses

Table 2
Strategies to build resilience in nurses at the individual, group, and organisation level

Individual level strategies

Engage in cognitive reframing to promote psychological flexibility and adaptability in the work environment
Develop emotional insight to identify risk and protective factors that facilitates emotional toughness within the environment
Ground connections with family, friends and colleagues
Maintain work–life balance to foster career and personnel goals
Use critical reflection to problem-solve and build resolutions to help guide in future situations
Engage in reconciliation to reaffirm professional commitment and find meaning and congruency between work life and personal beliefs and
value system
Maintain a positive attitude through humour, laughter, positive thinking techniques, visualizations and positive affirmations
Engage in extracurricular activities such as exercise, volunteerism and social network groups
Seek out a trusted mentor to provide professional and personal guidance

Group level strategies (nursing)

Analyse the organisation’s current work environment by conducting an assessment using the AACN’s Healthy Work Environment
Assessment
Implement AACN’s Healthy Work Environment standards
Conduct a Magnet Recognition Readiness assessment
Achieve Magnet Recognition Status
Establish a model of Shared Governance within the healthcare organisation at the organisational and unit level
Implement New Graduate Nurse Residency programmes such as the University Health System Consortium (UHC) and American
Association of Colleges of Nursing (AACN) Nurse Residency programme
Implement Mentorship programmes for new graduate and newly hired nurses
Establish a mechanism for formal and informal debriefing sessions for nurses involved in traumatic/stressful patient and family situations
Personal resilience workshops for nurses

Organisation level strategies

Implement Employee Assistance programmes
Provide professional development programmes such as:
Interdisciplinary effective communication
Coping strategies
Effective team building/teamwork
Emotional intelligence
Conflict management and resolution
Stress reduction workshops
Implement and enforce a Zero Tolerance policy for disruptive behaviours (bullying/horizontal violence)
Promote personal health incentives:
Smoking cessation classes
Workout/gym facilities
Free health screenings

Nursing 2010). Further evidence of burnout is associ- the nurse. In many environments, nurse salaries or
ated with negative health outcomes such as psycholog- bonuses are tied directly to the patient satisfaction
ical distress, somatic complaints, and alcohol and scores affecting the economic aspects of a nurse. Study
drug abuse (Vahey et al. 2004). Furthermore, disrup- findings by the Institute of Medicine (IOM) (2004)
tive behaviours including bullying, abuse, and hori- noted that many factors directly related to the practice
zontal violence causes physical and psychological environment impact nurses’ level of job satisfaction,
harm to nurses resulting in a cycle that leads to ongo- decisions about leaving the practice and, ultimately,
ing oppressed group behaviours (Roberts et al. 2009). the quality of patient care.
Additionally, outcomes of patient satisfaction surveys, Nursing administrators/managers can support a
conducted by most healthcare institutions, depend healthy work environment by implementing the Amer-
heavily on patient satisfaction with nursing care. ican Association of Critical-Care Nurses (AACN)
Vahey et al. (2004) noted that the environments that Healthy Work Environment Standards (American
contribute to nurse burnout may be the same ones Association of Critical-Care Nurses 2005) within their
that lead to lower patient satisfaction scores. Ulti- organisations that promotes excellence in nursing care.
mately the responsibility for hospital success may be The standards focus on skilled communication, true
perceived by some nurses to rest squarely on the collaboration, effective decision making, appropriate
shoulders of their profession – yet another stressor for staffing, meaningful recognition and authentic leader-

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P. L. Hart et al.

ship. The first step for nursing administrators/manag- nursing work arena, increasing new graduate retention
ers is to conduct an assessment of their organisation’s rates, promoting job satisfaction and protecting
current work environment using the AACN’s Healthy patients by enhancing patient safety and quality care
Work Environment Assessment tool to identify issues through a structured orientation and support system
within the work environment and to develop an (Krugman et al. 2006, Romyn et al. 2009, Bratt & Fel-
implementation plan to address the issues. zer 2011). In support of the nurse residency model, the
While support for each other is critical for nurses, National Council of State Boards of Nursing (NCSBN)
support from managers affects success or failure. advocates for healthcare organisations to adopt a tran-
Although internal resilience can be learned, it is not sition to practice regulatory model that endorses com-
solely the responsibility of the individual nurse. Nurses pletion of a transition programme during the first year
often leave the healthcare system due to burnout and of practice (National Council of State Boards of Nurs-
work related adversity. Those who remain may also ing 2009). In addition, the Commission on Collegiate
affect patient care outcomes because of their inability Nursing Education (2008) has developed standards and
to cope with the organisational situations. The organi- an accreditation process for post-baccalaureate nurse
sation also has a responsibility to provide support and residency programmes.
respect the autonomy of these highly trained profes- One example of a successful nurse residency pro-
sionals. It seems logical that if organisational culture gramme is the University HealthSystem Consortium
includes values that promote resilience, then new and (UHC) and the American Association of Colleges of
experienced nurses will commit to the organisation and Nursing (AACN) residency programme. The UHC and
contribute to the overall quality of care. This is, after the American Association of Colleges of Nursing (2007)
all, what the Magnet hospitals have achieved. collaborated and developed this year-long residency pro-
In particular, new nursing graduates face a multi- gramme based on an evidence-based curriculum. Cur-
tude of challenges in adaptation to the work setting. rently, there are 81 practice sites participating in the
Casey et al. (2004) reported that graduate nurses’ role UHC/AACN residency programme. Research supports
adjustment was most difficult between 6 and positive outcomes for nurses enrolled in the UHC/
12 months after hire and that the majority did not AACN residency programme such as improved clinical
have the confidence and competence to assume a safe skills and abilities; increased ability to organise and pri-
level of patient care. Sources of their concerns include oritize patient care; effective communication skills with
difficulty in work/personal life balance and dissatisfac- healthcare providers, patients and families; and
tion with the work environment, including career decreased turnover rates (Pine & Tart 2007, Williams
development, salary, schedules, patient care issues, et al. 2007, Maxwell 2011).
lack of power to make effective changes and incivility Workplace characteristics such as autonomy, control
in the workplace. Laschinger et al. (2009) found that over the practice environment, and collaborative
lower levels of burnout (emotional exhaustion) are working relationships have been empirically linked to
associated with workplace conditions that foster sup- a perception of structural empowerment in nurses.
port of nursing practice and civil working relation- Nursing administrators/managers have been front
ships, and promoted a sense of empowerment. Hodges runners in implementing shared governance structures
et al. (2008) noted that the leap of the new nurse within healthcare organisations. Key components in a
from education into practice often triggered the acute successful shared governance model include auton-
awareness of where they did or did not fit, and fos- omy, independence in practice, accountability, par-
tered the reconciliation between what they had been ticipation, empowerment, collaboration and shared
taught and the unexpected realities of the practice set- decision making (Anthony 2004). Organisations
ting. Yet their coming to terms with this dissonance, that promote decision-making authority at the work-
particularly under a supportive workplace, was also force level empower their nurses to be more responsi-
the beginning point of growth of resilient behaviour, ble which promotes ‘ownership’ of their jobs.
self-efficacy and professional savvy. Healthcare organisations that empower their nurses
A strategy many nursing administrators/managers are promoting a supportive work environment that
support is the implementation of nurse residency pro- builds trust within the work environment. Organisa-
grammes for new graduate nurses (Krugman et al. tional culture that has trust embedded in the founda-
2006, Romyn et al. 2009, Bratt & Felzer 2011). Nurse tion has been shown to affect nurses’ job satisfaction,
residency programmes have been successful in assisting organisational commitment, role clarity and empower-
new graduate nurses to transition to practice within the ment (Laschinger et al. 2000, 2001, Ray & Marion

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 Resilience in nurses

2002). Nurses working in organisations where trust is At the organisation level several strategies are
paramount may experience the work environment as applicable to support and build resilience within the
more supportive. organisation’s workforce. Employee Assistance pro-
An example of this type of supportive work environ- grammes (EAP) provide help to employees dealing
ment is Magnet hospitals who have received recogni- with personal issues and problems that might affect
tion from the American Nurses Credentialing Center their work performance, health or well-being. Organi-
(ANCC), a part of the American Nurses Association. sations provide EAP services free or at a reduced cost
Magnet recognition attests to the quality of the nurs- to their employees. Professional development pro-
ing care provided by the hospital and indicates nursing grammes that target resiliency building behaviours in
involvement in decision-making about care delivery. employees is beneficial in enhancing and providing
Magnet hospitals are characterized by their ability to employees with tools and skills to deal with the daily
provide a supportive, collaborative, interdisciplinary stresses and frustrations of the work environment.
environment that promotes the professional practice These programmes might include topics such as inter-
of nursing. These hospitals foster decentralized deci- disciplinary effective communication, coping strate-
sion-making by nurses; autonomy in nursing practice; gies, effective teambuilding/teamwork, emotional
control of and over nursing practice; collaborative intelligence, conflict management and resolution and
management and physician relationships with nurses; stress reduction.
access to information, support and resources; and Disruptive behaviours (bullying, horizontal violence,
opportunities for growth and development. Although abuse) within healthcare organisations result in physi-
all healthcare agencies may not aspire to this creden- cal and psychological harm to nurses. Negative conse-
tialing process, the values and workplace characteris- quences such as fear, loss of self-esteem, anxiety,
tics that are evident in the Magnet hospitals are those depression, demoralization and feeling vulnerable can
that are most likely to provide the trust and support result when nurses are victims of disruptive behaviours
needed to promote resilience in nurses. (Hutchinson et al. 2006). The impact of disruptive
Additional strategies that nursing administrators/ behaviours for organisations includes a decreased
managers can implement to build resilience in nurses quality in patient care, workforce job dissatisfaction
include formal and informal debriefing sessions for and poor morale (Yamada 2008). In addition, disrup-
nurses involved in traumatic/stressful patient and fam- tive behaviours within an organisation can lead to
ily situations, mentorship programmes for new gradu- problems with retention and recruitment of nurses
ate and newly hired nurses, and personal resilience (Jackson et al. 2002). Disruptive behaviours can have
workshops for nurses. Nurses care for patients with a huge financial costs to organisations related to a loss
variety of diagnoses and outcomes that may produce of productivity and employee commitment with esti-
powerful emotional responses on the part of the nurse. mates ranging from $30 000 to $100 000 per victim
Providing an avenue for nurses to debrief from these (Simons 2008). Implementation and enforcement of a
types of situations may be a cathartic process to Zero Tolerance policy for disruptive behaviours is
relieve stress, anxiety and built up emotions. essential to present a united front in promoting a safe
Personal resilience workshops for nurses have also and healthy work environment for nurses.
been effective in helping nurses to manage the chal-
lenges within the work environment (McDonald et al.
Conclusions
2012). McDonald et al. (2012) developed a work-
based education programme to strengthen personal This integrative review provides vital information to
resilience in nurses. The programme focused on topics nursing administrators/managers about the concept of
such as developing mentoring relationships, building resilience within the work environment. Becoming
hardiness, maintaining a positive attitude, intellectual aware of contributing factors to the need for resil-
flexibility, emotional intelligence and reflection within ience, intrapersonal characteristics that foster resilient
a participatory learning group format. Nurses reported behaviour, and successful strategies to build resilience
positive outcomes from the programme such as in nurses can help in recruiting and retaining nurses
enhanced self-confidence, self-awareness, communica- within the workforce. It is important for nursing
tion and conflict resolution skills, In addition, nurses administrators/managers to understand why some
were able to build and strengthen relationships with nurses are resilient in the workplace and others are
their peers and to develop a support network within not in order to provide support, foster a positive orga-
their organisation. nisational work culture, and to develop programmes

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