A Concept Analysis of the Phenomenon of Resilience

The purpose of this paper was to describe and clarify the construct of resilience in effort to identify its importance and usefulness to nursing. A synthesis of the relevant literature defining and clarifying the concept of resilience, its attributes, antecedents and consequences are presented. The definitions of the concept of resilience through the years have been relatively similar in their inclusion of the elements of positive adaptation or coping in the face of severe stress or adversity. However, the terms that have been used to describe this phenomenon differ and include invulnerability, hardiness, and stress resistance. The concept of resilience is one that can be used by nurses when caring for people who are facing physical, psychosocial and cultural adversities within their environment. It is unclear whether resilience is an outcome of an intervention, or a moderator or mediator to coping behaviors. What becomes clear is that more nursing research needs to be done to examine the role of resilience in health promotion, acute care, and chronic illness.


Introduction
The term resilience has been defined for over two hundred years. Webster provided the first definition of resilience in 1824 as the "ability of a stressed body to recover from or adjust easily to misfortune and change" [1][2][3][4]. A description of resilience can also be found in American literature. In F. Scott Fitzgerald's, The Great Gatsby, the narrator Nick Carraway references the concept of resilience as he describes the characters in the book continually moving in the face of adversity not unlike a boat battling the tide. Through the years, basic scientists, psychologists, sociologists, and health care professionals have used the term resilience. Indeed, although the concept has been used by a variety of disciplines, most have incorporated Webster's definition in their concept development and research.

Historical Perspective
There is a plethora of literature that refers to the term resilience. A literature search was conducted using CINAHL, PsychINFO, Econlit, Medline and Applied Science and Technology entering the key word resilience. The search returned over 10,000 citations that included the word resilience used by a variety of disciplines, including, but not limited to economics, engineering/ecology, psychology, sociology and nursing.
The earliest emergence of the concept of resilience was relative to children with psychiatric disorders. In the 1970s invulnerability was used to describe children who thrived despite less than optimal circumstances and risks [1]. Others defined invulnerability in college students as the style of attributing negative occurrences to external and specific factors [5]. Robinson and Fields defined invulnerable children as those who cope and function in spite of extreme stress [6]. Gayton et al. in a psychological study of children with Cystic Fibrosis as well as their families, and siblings described the term resilience as hardiness or the ability to persevere or survive during unfavorable conditions [7].
There is some confusion in the literature whether the concept of invulnerability is analogous to resilience. For example, adolescent invulnerability has been related to risk-taking among adolescents [8]. Hardiness may be incorporated in the concept of resilience in that it includes positive responses to stressful circumstances [2]. Some would argue that hardiness and resilience are redundant concepts in that they result in positive outcomes in response to severe stress [9].
In 1982, Werner introduced the concept of resilience as the "ability to bounce back" from adversity. In a longitudinal study, Werner found that most children who were born with extreme stressors had adapted into functional adults by the age of 40 [10]. Rutter in his study of children with mentally ill parents found that these children functioned successfully despite the adversities they faced, defining this as resiliency [11]. In the 1990s, the literature focused on childhood resilience as competent functioning under stress [3], coping appraisal [12] and competence in the face of adversity [13]. In summary, the earliest work on resilience focused on children and adolescents and their reactions to extreme stress. Descriptions of resilience included invulnerability, hardiness, and competency under stress, coping appraisal and adaptation under extreme stress.
In the ensuing years, the concept of resilience moved from research on children to other populations, including adults, older adults and ethnically diverse populations. In the 2000s, research on resilience focused on adults. De Santis [14] in his integrative review of the literature explored the concept of resilience in the context of HIV infection. Using the working definition of resilience as a positive response to negative life events, De Santis concluded that resilience could be applied to HIV infected individuals, although the conceptualization was still unclear. Other studies have focused on resilience in older adults. Hildon et al. [15] defined resilience as "flourishing despite adversity" Adversities included both health-related and psychosocial stressors. Windle et al. [16] examined psychological resilience in older age as a personality resource that influences successful outcomes to stress. Resiliency of ethnic minorities, specifically African Americans, also became a focus of the research.
Brown [17] defined resilience as the ability to overcome adversity with resilience being taught through racial socialization and social networks. Others researched African-American adults after experiencing severe trauma and their ability to overcome adversity [18] or as an intervention in African-American adults who were experiencing the chronic illness of diabetes [19].
In the 2000s, literature on resilience also focused on families and communities. Greeff and Toit [20] studied family resilience, the ability for positive adaptation, in remarried families. Quinn described the challenges of preparing and promoting resilience in minority communities during a pandemic.
In summary, the historical emergence of the concept of resilience began with research on children who were facing adversity [3,10,11,13]. The subsequent literature on the concept also focused on adults [14] and older adults [15,16]. Resilience in African-American populations was also studied [17][18][19]. Further, recent literature also used the concept of resilience in studying families' and communities' responses to adversity [20]. Resilience was also linked to adaptation, coping strategies and protective factors as the concept evolved to the present [19].

Evolutionary Development of Resilience
The definitions of the concept of resilience through the years have been relatively similar in their inclusion of the elements of positive adaptation or coping in the face of severe stress or adversity. However, the terms that have been used to describe this phenomenon differ and include invulnerability [1], hardiness [2] and stress resistance [3]. In the field of economics, resilience has been used as a quantifiable economic indicator of a society's ability to recover positively from severe economic downturns. In the engineering literature, resilience is used to determine the resistance of substances to adverse forces. The working definition of resilience in engineering is the ability of a substance to spring back to its original shape [21]. Roth and Von Colliani [22] defined resilience as a personality trait that protects against the adversities of life. They described the resilient individual as flexible, resourceful, and inventive as they confront life distress. Silk et al. [23] described resilience as a dynamic process where positive adaptation occurs in the context of adversity. They conceptualized the process of resilience as continuous, active, and changing with developmental transitions when new risks, vulnerabilities, and emerging strengths emerge. Protective factors are biologic and social, including lower stress reactivity, and positive social interactions. According to Silk et al., resilience occurs when the individual confronts new risks and established protective factors are challenged leading to successful adaptation. Windle [24] defined resilience as effectively negotiating, adapting to, or managing significant sources of stress or trauma. According to Windle, the experience of "bouncing back" or resilience varies along the lifespan. Assets within the individual and the environment facilitate adaptation.
The construct of resilience in the social sciences and health is rooted in the stress and coping literature. Werner and Smith's seminal work following children born in Kauai, Hawaii from birth to age 40 described multiple adversities for this group, including poverty, complications at birth, parental psychopathology, and family dysfunction. Comparing these children with children without such adversities, Werner [10] found that one-third of the high-risk group functioned well by adulthood despite the adversities they faced, labeling this attribute as resilience. Further, the researcher found that resilience was a developmental phenomenon that appeared in infancy.
The focus of the early research focusing on children appeared to focus on resilience as a protective factor to combat adversity. Garmezy [3] found that children at risk for mental illness were able to function competently despite their adversities. They had a commitment to function in the face of difficult circumstances, what Garmezy called stress resistant children. This work added to the belief that resilience was a predictor of successful adaptation and coping and in some ways protected the individual from dysfunction. However, as the concept evolved other protective factors were described. Optimism and hope were found to be protective factors in later research [25][26][27][28].
Resources to promote resilience were also identified as the concept evolved. These resources were characterized into individual characteristics, social support and family congruence. Individual characteristics included self-esteem, a feeling of self-worth as a protective factor to resilience [11]. Resilient individuals were also socially responsive [25]. They had a belief that they can control their lives. Werner and Smith called this control an internal locus of control. Control has also been called "personal medicine" where one uses their inner resources to take control over their lives [29]. One of these inner resources discussed in the literature was self-reliance or the way resilient individuals take control of their own destiny [20,25,30]. Selfefficacy as an attribute of resilience also emerged in the literature as the concept evolved. Self-efficacy was seen as individual confidence to successfully face life's situations [11,31]. The concept of self-efficacy appears to be similar to self-reliance.
Jacelon [32] studied the traits of individuals that would be defined and as resilient. Optimism and being engaged in life were strong indicators for resilient behavior. Optimism was seen as a correlate to resilience [25][26][27]. Grote and Bledsoe [33] found optimism to be a protective factor for women at risk for depression. Tusaie et al. [34] found that optimism was a predictor of psychological resilience. Hope is another predictor of resilient individuals [27,28] or a resilient factor [35]. In evolution of the concept of resilience other individual characteristics emerged. They included independence and autonomy [11,32]. Wagnild [30] added the concept of existential aloneness, the knowledge that each individual is unique and that there are times that they must face adversity alone. Development is another characteristic impacting resilience. Werner and Smith found that resilience occurs as early as infancy and proceeds through midlife along a developmental continuum. Others also described the impact of development on resilience [36]. In summary, the individual characteristics that are resources to resilience are self-esteem, a perception of control of their situation, social responsiveness, optimism, hopefulness, and their stage of development. Some of these characteristics may be viewed as attributes of the concept of resilience, such as self-reliance, self-esteem and social responsiveness. Optimism and hope may be viewed as antecedents to resilience.
Social support is a second category of resources for resilience found in the evolution of the concept. Support was needed for family congruence, and included family members and friends [10,17,37,38], religious organizations [39], schools, and the community [40]. In sum, "it takes a village" to provide social support as a resource for resilience. Social relations are seen as fostering resilience [41]. The concept of social support may be seen as an antecedent to resilience.
In conclusion, the concept of resilience has evolved over a 50 year time in the literature. The literature supports resilience as being dynamic, environmentally interactive and developmental in nature [36]. There is a question of whether the concept is a trait or a process,

Current Definition
After reviewing the literature, the following definition of resilience is given: Resilience is a dynamic concept that describes the ability of individuals, families and groups to successfully function and adapt and cope in spite of psychological, sociological, cultural and/or physical adversity. Resilience, a trait and a process, was found in individuals along the developmental continuum.

Attributes
After an extensive review of the literature on resilience, there are attributes that help distinguish the concept from other concepts. These defining attributes are: (1) self-esteem, (2) self-reliance, and (3) social responsiveness.

Self-esteem
According to Webster's Unabridged Dictionary, self-esteem, a noun, is a belief in oneself. Relative to resilience, self-esteem is seen as the protective mechanism of self-worth that allows the individual to successfully cope with severe challenges and adversities [11]. Individuals with low self-esteem are found to be not resilient.

Self-reliance
According to Webster, self-reliance is a reliance on one's own powers, judgment and abilities. The literature supports self-reliance as an attribute of resilience in that resilient individuals and groups have a sense of control, independence, autonomy and "existential aloneness" in the knowledge that they are empowered to control their own destiny in the face of adversity [11,3,20,25]. Self-reliance has also been referred to as "personal medicine" or the ability to expand an inner self to take control of their lives [29].

Social responsiveness
Social responsiveness is the attribute of resilience, which allows the individual or group to interact competently with their environment [10]. Through social interaction and responsiveness, they are able to face adversity, relate to helpful others and reduce negative reactions [11,25].

Antecedents
Social support is the most common antecedent to resilience in the literature. It is the assistance of others in time of need and adversity. Supportive relations are seen as fostering relations [41] in times of adversity. Resilience requires social support from a variety of sources, including family members and friends [10,17,37,38], religious organizations [39], schools [40].
Other antecedents to resilience found in the literature are optimism and hope. Both are needed for resilient individuals to see a successful future in the face of adversity. Optimism is seen as a correlate to resilience, the more optimistic the individual, the more resilient the individual [25][26][27]. Optimism engenders a positive participation in life and therefore promotes successful adaptation to stressors. Using the risk-resilience framework, Grote and Bledsoe [33] viewed optimism and as a protective factor for women at risk for postpartum depression.
Lastly, Tusaie et al. [34] found that optimism was a predictor of psychological resilience. Hope provides the individual with the ability to view a successful future [27,28]. Hope assists the individual to become resilient in the face of overwhelming stressors [35]. Adversity is also an antecedent to resilience found in the literature on resilience. Adversity is defined as extreme and multiple stressors that impact lives. Lazarus and Folkman [42] describe stress as the interaction between individuals and their environment. Stressors include poverty, complications at birth, parental psychopathology and family dysfunction and physical and psychological illness [3,11,33].

Consequences
One consequence of resilience are problem-focused coping and in the face of adversities. Lazarus and Folkman [42] state that individuals, who cognitively appraise stress and view it as a challenge, rather than a threat, are confident in their ability to mediate stress. The attributes of resilience and self-esteem assist the individual to engage in problemfocused coping. Gilliespie et al. [31] identified four consequences of resilience psychological and physical integration, the development of personal control, psychological adjustment and personal growth.

Model Case
A model case is an example of the concept that demonstrates all of the defining attributes [43]. Maria is a 25 year old left-handed female who grew up in a dysfunctional family environment. She is a first generation Italian-American and had been the primary caregiver for her widowed father and special needs older brother before getting married. As the only female in the household, she took on the role of matriarch often at the expense of social activities during her high school years. She did have the support of her childhood friend, Gail, who would help her prepare dinners and clean the house on occasion. Maria is a social, caring, positive individual who takes her challenges in stride. She is newly married, and has a family history of multiple sclerosis (MS). She suddenly complains of "dragging of her leg". Her mother died when Maria was 15 years old of MS and Maria is worried that she might also have the disease. She is brought into the emergency room by her husband where she is diagnosed with a right thrombolytic stroke. She develops severe weakness on her dominant left side, but can speak and communicate. She is admitted to the hospital and feels that her "body has failed her. " Still, she is able to utilize humor with the nurses and doctors as a means of coping with the situation. She is extremely positive with family and friends and despite a fear of needles; she undergoes multiple tests to help determine a causative factor for the stroke. During her recovery, she interacted sociably with the doctors, nurses, and physical therapists and asked her mother-inlaw if she and her husband could stay with her for a while. "It won't be long" she stated. "I intend to go to physical therapy and do what I have to do because I have been through other crises in my life and have done well. I am in control of this. " When asked by the nurses how she remains so positive, Maria replied "I rely on the support of my family and friends, who love me, as well as my belief in God. I have always been independent, and will continue to address any adversity in my life as a challenge to overcome. This is my Everest and I will make it to the top. " Over the next year, Maria worked with the physical therapists to make a complete recovery from the stroke with minimal residual. She was diagnosed with anti-phospholipid syndrome, and despite having to take blood thinners, she has continued to lead a full active life as a married, working mother of two boys.

Nursing implications and future considerations
Nurses interact with individuals, families, and communities at various stages of development. The concept of resilience is one that can be used by nurses when caring for people who are facing physical, psychosocial and cultural adversities within their environment. The phenomenon of resilience is important to nurses and policy-makers in the health care arena. Resilient attributes, including self-esteem and self-resiliency are patient-centered attributes that allow patients to cope with stressors in their environment. Future research should include the variables of hope, well-being, social support, and health practices to name a few. There is an on-going need to study resilience and explore the possibilities of resilience-based interventions. Nurses can capitalize on unique opportunities for promoting positive adaptation. There is a widespread and diverse body interested in investigating this endeavour as evidence by the literature search. Conducting a concept analysis of resilience and clarifying the attributes, antecedents, consequences and empirical referents of the term are simply contributions to the realization of these implications for future theory, research, and practice. Helping individuals to strengthen and improve their resilience in the face of the challenges and adversities will help achieve positive nursing outcomes. Resilienceenhancing interventions can be developed and used by nurses working with individuals in clinics, acute-care settings, and chronic care settings. These interventions can focus on creating socially supportive environments, a protective factor of resilience, as theorized by Werner and Smith. Other interventions can be developed to help with social support, hope and self-efficacy. These interventions can include focusing on helping individuals to focus on the positive aspects of their life, rather than the negative.
The findings of this concept analysis can contribute to a comprehensive knowledge base that sheds light on the "good" outcomes of resilience in individuals that can be used by professional nurses in a variety of healthcare settings.