Exploring nurse perceptions and experiences of resilience: a meta-synthesis study

The aim of this study is to understand nurse resilience and to suggest directions for future research through the process of synthesizing and integrating qualitative research results on nurse resilience-related experiences.

We used a meta-synthesis methodology, which provides broad understandings of social phenomena, to integrate the findings of qualitative studies [26]. Since meta-ethnography is an interpretive approach suitable for higher-level analyses and the formation of new interpretations beyond the discoveries of individual qualitative research [24], it is suitable for the purpose of this study, which is to synthesize and newly interpret research on nurse resilience experience. We followed the meta-ethnography method, which is suitable for both preserving the interpretations of the primary data and forming new interpretations, theories and models [27]. We applied the seven steps of the meta-ethnographic process by Noblit and Hare [24]: (a) getting started, (b) deciding what is relevant to the initial interest, (c) reading the studies, (d) determining how the studies are related, (e) translating the studies into one another, (f) synthesizing those translations, and (g) expressing the synthesis.

The research questions were:

This review was prepared in accordance with ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research Statement) guidelines [28]. This meta-synthesis study was registered (CRD42021275787) with PROSPERO, which is the International Register of Systematic Reviews.

We used the narrative literature review method. As this method is mainly used for searching literature representing the entirety of the phenomenon of interest, it is suitable for meta-synthesis studies [25].

Before the literature search, the two authors discussed the search strategy and databases to be used to search for appropriate articles that meet the purpose and inclusion criteria of this study. The authors selected PubMed and EMBASE, which are considered the most important databases for literature searches in the medical field [29], and included Web of Science to broaden the search to the field of social science. In addition, CINHAL, a nursing database, and PsycINFO were important to include due to the psychological nature of the concept of resilience. Thus, literature searches were carried out across five databases overall (PubMed, CINAHL, EMBASE, Web of Science and PsycINFO). The representative search terms used in the search were “Nurses”, “Resilience, Psychological”, “Qualitative Research”, and “Hermeneutics” from the list of Medical Subject Headings (Mesh terms). The search terms were adapted according to the index terms of each database. The search terms were used with the Boolean operators “AND” and “OR” in different combinations. The search strategy of this study is presented in supplementary material Table S1. A flow chart of the systematic review of literature selection process of the present research is presented in Fig. 1. A review study on a similar subject was conducted in 2012 [30]. In our search process we found that relevant studies had increased rapidly since 2011. Therefore, we limited the search results to the last 10 years to achieve a synthesis focusing on the latest research results.

The inclusion criteria required qualitative studies that were: (a) aimed at exploring the resilience of nurses, (b) published from January 2011 to September 2021 (c) peer-reviewed journals (d) published in English, and (e) full-text searchable. The exclusion criteria were (1) nurse experiences were not reported separately, (2) mixed methods were used but qualitative data could not be extracted or (3) necessary qualitative depth was lacking in the data analysis.

Through the search procedure, 1020 studies were identified. 528 studies were excluded as duplicates in Endnote, and the two authors independently reviewed each title and abstract, thereby excluding 394 studies. When the two authors independently reviewed the full-texts and discussed any disagreements, 82 studies were excluded because of a lack of focus on nurse perspectives, an inappropriate topic, insufficient qualitative criteria, or because the full text could not be found. After this process, 16 studies remained for inclusion (Fig. 1).

The Critical Appraisal Skills Programme (CASP) checklist, which contains 10 questions for assessing the reliability and rigor of individual studies, was used to appraise the 16 studies [31]. Two authors independently evaluated the 16 included studies using the CASP checklist. After the appraisal, the two authors compared the CASP results, and any disagreements were resolved through discussion. The degree to which the studies met CASP was evaluated to be 70% for 4 studies, 80% for 9 studies, and 90% for 3 studies. Since all the studies were evaluated as being 70% or higher, none were excluded from the evaluation process (Table 1).

Two authors independently reviewed the studies in detail. Each author read the studies line by line and tried to derive meaningful concepts by extracting codes. Data extraction for the study was performed using a custom form in Microsoft Excel, including author details, participant characteristics, methods, and original citations [27]. Disagreements between the authors were solved through discussion.

Based on the meta-ethnography process [24], the 16 studies were independently read repeatedly by the two authors, data analysis was performed, and then the extracted data were summarized as concepts. In more detail, after organizing the papers in chronological order, the two authors independently read the 16 studies, repeatedly. They then summarized and extracted meaningful concepts and themes. The two authors compared the themes and concepts of the first paper with those of the second paper, and then compared the common themes of those two papers with the third paper to derive concepts and themes. To synthesize the key concepts and broader themes, this process was repeated until the final study. To extract the key concepts, the studies were read several times, and the key concepts of each study were listed and analyzed for comparison. The key concepts were formed based on the ‘first-order construct’ of the study. In the meta-ethnography analysis process, the data is divided into ‘first-order construct’, ‘second-order construct’, and ‘third-order construct’ [32]. The ‘first-order construct’ is the original study participant’s daily language as expressed in their own language in the original study, the ‘second-order construct’ is the researcher’s interpretation based on the ‘first-order construct’, and ‘third-order construct’ is a new interpretation of ‘second-order construct’ [32, 33]. In this study the authors of the current paper extracted the key concepts of the ‘first-order construct’, then compared the similarities and differences to form the ‘second-order construct’, and finally derived the ‘third-order construct’, which represented the main themes of the current study, by abstracting the ‘second-order construct’. During this process of analysis and synthesis, the two authors continued to discuss their differences of opinion based on their respective academic and clinical backgrounds. The final analysis step, “expressing the synthesis,” was accomplished by collating the discussion results. In order to confirm the value of the data, the researchers asked one incumbent nurse and one nursing professor to confirm the appropriateness of the expression of the results and the choice of terminology, and after the discussion the results were amended accordingly and finalized. The quotes that best expressed each sub-theme were identified and are presented in the results.

As this study is a review study, as a meta-synthesis, human participants were not included. Therefore, an ethical committee review was not required.

The sub-themes included in theme 1 were “recognizing and acknowledging signs of adversity” and “striving to develop oneself”. The nurses tried to find solutions by focusing on the signals that they had encountered adversity, and making an effort to grow through that adversity rather than collapse under it.

The nurses did not deny the signs of adversity, but recognized and acknowledged them. The nurses looked inside themselves to find problems and tried to reflect on themselves [A2-A5,A8,A11,A13–14,A16]. They tried to focus on the current situation [A2,A5,A8–9,A11–14] and showed an attitude of acceptance of the situation they were in rather than one of avoidance [A8–9,A11–14]. They believed in their abilities [A2,A5,A6,A9–10,A12–14], tried to express their feelings honestly [A2,A6,A10,A11,A13], and tried to recognize the warning signs of stress rather than ignore them [A5,A9,A11,A13]. They showed themselves as focusing on the state and demands of their bodies and emotions [A5–6, A8,A10–11,A16].

“It is difficult....I feel it is a most difficult thing to reflect on my own feelings. I can understand other people, but I do not understand myself. I think I have experienced a kind of burnout.” (A2).

“I thought of ways when something happens so that one can go away, sit down and reflect and then maybe come up with whatever your own strategies are to come back stronger. So if the same thing comes at you again, you know where to run, which direction is faster” (A11).

Rather than despair, the nurses wanted to grow on their own. They tried to maintain their physical health [A3–4,A11] and recognized a sense of self-efficacy [A5–6,A9,A11,A13–15]. In addition, they thought about and developed various ways to take care of themselves [A2-A4,A9,A11–15]. They were confident that they could overcome the adversity [A5–6, A9, A11, A13–15] and tried to control their emotions [A2,A5–6,A9,A11,A13–15]. Nurses tried not to ignore what others had to say and to learn from their experiences and expertise [A2–4,A6–7,A9–10, A16]. They tried new challenges [A2–5,A9,A11,A13] and had varied thoughts to solve problems [A2, A5, A9, A11–14]. The nurses showed patience and a willingness to move forward [A5,A9,A11,A13–14].

“You know more or less that you have to do it and it is going to be tough going. The task could be from manageable to unmanageable depending on what is happening at the moment. I’m able to cope with stress.”(A13).

The nurses maintained a optimistic view toward life when overcoming life adversities [A1,A3–7,A9,A14–15] and maintained a sense of humor at work [A3–4,A6,A11]. They were grateful for life [A3–4,A6–7,A12] and tried to heal themselves by living a life of helping others [A2–4,A6,A15]. They remembered the good memories they had in the past, and drew positive thoughts from them [A1–2,A5–6,A15]. They found enjoyment and pride in what they did [A1,A5–6,A11,A15].

“But I try to look at the positive stuff. .. what we are able to do, what changes we were able to make as a result of a catastrophe or just a bad outcome. .. just pull my sleeves up and get in there and get it done and when I can, I do try to encourage communication and good feelings.” (A5).

““I think every type of nurse has their own type of black humor but I realized a lot of it is a coping mechanism and a way of protection to get yourself through the day” (A11).

Nurses tried to overcome the adversities they faced while enjoying life on their own terms [A1–2,A5,A11]. They tried to live a regular and healthy life, enjoy various leisure activities [A1–2,A5,A11,A13] and enrich their lives happily while creating their own hobbies [A1–2,A5,A13]. They coped with the situation by developing their own coping behaviors for managing crisis situations [A1–2,A5,A11,A13].

“You have to enjoy what you are doing. If you hate your work, it will be a constant stress. I feel that I don’t get stressed about it because I feel that no problem is difficult.” (A13).

“The joy of working is like a hurdle … like jumping over the hurdle. Each time I jump over a hurdle that I cross, there is always some satisfaction in the job.” (A13).

The sub-themes “staying away from stress” and “getting comfort through positive interpersonal relationships” were included in theme 3. Nurses were shown to develop their own strategies when overcoming adversities. They tried to stay away from situations that were stressful to them and formed their own defenses through positive interactions provided by wide-ranging human relationships. These methods of overcoming adversity were their own individual strategies learned through their own experiences.

Nurses had to face varied sources of stress, but tried to avoid them, such as by trying to not create stressful situations or focusing on stress [A1,A9,A10–11]. They tried to maintain a work-life balance so that neither aspect became too large or too small, breaking the balance [A5–6,A8,A10–12]. In addition, by thoroughly separating their work and life, they tried to thoroughly protect their private life, avoiding the intrusion of work. They tried to respect their own privacy [A5–6,A8,A10–12].

“Sometimes, I can’t control myself. In such situations, I attempt to distance myself from that situation or the immediate environment. In these conditions, I ask my colleagues to continue care delivery and then, I leave the situation. I never stay in such a situation because I know that my presence will aggravate the problem. Thus, I leave that situation and start providing care to another patient.” (A10).

“I think that the only way for me to stay resilient is to keep stepping away from the bedside, because that’s where all the stress is for me, it’s at the bedside. You need to remove yourself from the situation” “I have to have this proper balance and this little routine to maintain a healthy, functional life, and I think the younger ones know that which is good.” (A11).

In their professional positions the nurses developed a variety of interpersonal relationships, including relationships with patients, colleagues, and families. Nurses received comfort from their relationships with friends [A1,A3–5,A7,A10–12,A14–16] and comfort and support from their families [A1,A3–5,A7,A11–12,A14–16]. The nurses tried to maintain good relationships with their colleagues and other nurses and as colleagues they helped each other in difficult situations [A1–5,A7,A10–16]. In addition, they tried to grow one step at a time by orientating their own future direction through role models and mentors they could imitate [A1–2,A6,A11–12, A15], and they shared their feelings with people they could trust [A1–2, A5–6, A11–16]. They also received help from a mental health professionals for stress management [A6,A9,A12].

“It’s the people you work with. I have a lot of caring friends. I talk to my husband - he always backs me up. I think that how you deal with it... with another manager’s support. We meet for lunch sometimes — a laughs the best way — we quite often see the funny side.” (A4).

“Talking to colleagues because they know the scope of your job. They know what is happening in your ward, so they will be able to understand better.”, “I have good friends to whom I can confide my problems. I think it’s important you don’t bottle up your feelings too much, because you know you can just self-destruct if you’re not able to handle it. They may not be able to solve the problem; a listening ear does help.” (A13).

“I’m very fortunate as I have a large network of friends and colleagues that I can safely vent to or discuss things with or bounce ideas off that aren’t my staff. And I found that you really need that. It is pretty much a lifeline whether you’re a front-line manager or if you’re a director you need to have that core group of people that you can call and say, ‘Am I crazy’” (A11).

In difficult situations, nurses thought about how to live their future. Even in difficult situations, the habit of planning for the future and thinking about the future rather than staying in the present and despairing was exhibited by nurses [A2–4,A6–7,A9,A13,A16]. They wanted to develop themselves, to prepare for new assignments including difficult situations [A2–4,A6–7, A9,A14,A16], and to adapt well to new situations [A2,A7,A9,A13–14,A16]. They re-prioritized their work and tried to work according to their priorities [A5,A8,A13–16].

“I always take an experience as an opportunity to learn from it. To grow. I mean, no experience is bad. It may be a bad experience but you can learn from it and try to move on and try to make things better” (A13).

In difficult situations, nurses tried to gain the strength to overcome the crisis by reflecting on themselves being nurses [A2–4,A6,A9–13,A15–16] and on the value of their job [A2–4,A6,A9,A11–13,A15–16]. They took pride in their job, thought about the meaning and value of being a nurse, and tried to overcome crises while gaining satisfaction from the value of their work [A2–4,A6,A9,A11,A13–16]. They had a passion for their work [A2–4,A6,A9–16] and wanted to develop their knowledge and skills as nurses and upgrade themselves through individual development [A24,A6,A9,A12–13,A15].

“We are the backbone when patients come in. The nurse is the protector of the patient." (A14) "The patient survived because the nurse stuck out her hand and stopped the bleeding. I am proud of her.” (A11).

Resilience enhancement is an approach that maximizes human inner strength, and we can suggest an intervention that maximizes inner human resources by using mobile resources featuring excellent individual accessibility. Mobile health intervention applications have developed rapidly lately and their usefulness is recognized in nursing [45]. Recently, mobile health (mHealth) using smartphones for psychotherapy has been attracting attention as useful for the upcoming post-corona era [46]. Mobile applications can be useful resources for problem solving, and providing real-time information and stress reduction strategies for nurses in a variety of healthcare fields and settings [47]. In addition, since previous studies found smartphone app-based resilience interventions effective for resilience, emotional regulation, and psychological health promotion, the development of a smartphone app-based nurse resilience enhancement program can be expected based on the results of this study [48].