Factors associated with perceived resilience among undergraduate nursing students: findings of the first cross-sectional study in Palestine

This study was conducted in a cross-sectional design among undergraduate nursing students in the largest and main university with a nursing program in Palestine. The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.

The undergraduate nursing program in Palestine consists of 136 credit hours that can be completed in 4 academic years. Graduates are the future workforce of nurses who assume professional roles in primary, secondary, and tertiary healthcare practice.

The study population was undergraduate nursing students in the largest teaching university in Palestine. At the time of the study, there were approximately 1,200 students in the undergraduate nursing program. The sample size needed for this study was estimated using Daniel’s formula [20]. An online sample size calculator (http://​www.​raosoft.​com/​samplesize.​html) was used to calculate the sample size at a 95% confidence interval (CI) with a maximal margin of error of 5%. The sample size needed for this study was 292 undergraduate nursing students. To account for potential dropouts, we invited more than the sample size needed for this study.

The study participants were included in this study when they met the following inclusion criteria: 1) a current student in an undergraduate nursing program, 2) willing to provide informed consent, and 3) willing to respond to items in a questionnaire. Students who were in postgraduate nursing programs and those who already completed their undergraduate nursing program were excluded from this study.

The bulk of the accumulating literature refers to resilience as a psychological adjustment or an adaptive capacity [13, 21]. Resilience is thought to be promoted by cultural, social, and physical factors. Additionally, resilience is also affected by the extent to which a person negotiates for using these factors. Therefore, resilience is thought to be more than an outcome of person, process, risk, and context interaction [13]. Previous studies have reported that resilience was associated with self-efficacy, coping, mindfulness, and psychological adjustment [13, 21]. Self-efficacy refers to one’s belief that one can perform a specific task. It has been argued that behaviors are continuous interactions between environmental, behavioral, and cognitive factors. These interactions might vary by experience. Coping is the process in which one adjusts after an adverse event. People cope either by making efforts to solve the problem, reduce the emotional tensions that are associated with the adverse event, or tend to refrain from facing a similar adverse event. Mindfulness is the ability to attain a de-centered perspective on an event and respond flexibly to a negative thought. In this study, the Trait Resilience Scale was selected because it was based on a three-dimensional model of trait resilience (Factor 1: I can, Factor 2: I have, and Factor 3: I am) [22, 23]. Factor 1 measured the prosocial, cognitive, interpersonal, and school functioning of the students. Factor 2 measured relationships, role models, and social support the student had. Factor 3 measured self-perception in the self-regulation of the students. Additionally, the State-Resilience Scale was selected because it was based on a two-dimensional model of state resilience (Factor 1: I am and Factor 2: I have) [22, 23]. A theoretical framework is shown in Fig. 1. The scales were originally developed to measure resilience among students. In this study, the scales were used with permission from the developers to measure trait and state resilience among undergraduate nursing students.

The questionnaire that was used in this study consisted of 3 sections. The first section collected the sociodemographic, economic, and academic variables of the nursing students like gender, age, smoking status, place where the student was born and raised, where the student lived, whether the student needed to commute to the university or not, whether the student lived in a dormitory/residence or with parents, whether parents were divorced/separated, parents’ level of education, whether the student lived in a family-owned house or rented house, if the house had enough room per number of siblings or not, household income, whether the student worked a part-time job or not, whether the student had a chronic disease or not, whether the student experienced addiction issues or not, academic year, grade point average (GPA), study routine, and the number of hours of social media connection per day. In Palestinian universities, a GPA of 2 in the letters system is equivalent to C. Grades are converted to letters as follows: A: ≥ 90%, 88.0% ≤ A- < 90.0%, 85.0% ≤ B +  < 88.0%, 80.0% ≤ B < 85.0%, 78.0% ≤ B- < 80.0%, 74.0% ≤ C +  < 78.0%, 70.0% ≤ C < 74.0%, 65.0% ≤ C- < 70.0%, 63.0% ≤ D +  < 65.0%, 60.0% ≤ D < 63.0%, 45.0% ≤ D- < 60.0%, and E < 45.0%. These variables were shown to affect resilience among nursing and other healthcare students [13, 21, 24‐26]. The second section contained the Trait Resilience Scale which consisted of 18 items [22, 23]. The students had to rate each item of the scale on a Likert scale that had 5 options (strongly disagree to strongly agree). The third section contained the State-Resilience Scale which consisted of 15 items [22, 23]. The students had to rate each item of the scale on a Likert scale that had 5 options (strongly disagree to strongly agree). The ratings that were collected on the 5-options Likert scale were transformed into scores as: strongly disagree = 1, disagree = 2, neutral = 3, agree = 4, and strongly agree = 5. Scores on the Trait Resilience Scale could range from 18–90. Students were stratified into trait resilience categories based on their scores as: very low (score: 15–24), low (score: 25–34), moderate (score: 35–44), high (score: 45–54), very high (score: 55–64), and extreme (score: 65–75) [22, 23]. Scores on the State-Resilience Scale could range from 15–75. Students were also stratified into state resilience categories based on their scores as: very low (score: 18–29), low (score: 30–41), moderate (score: 42–53), high (score: 54–65), very high (score: 66–77), and extreme (score: 78–90) [22, 23]. Historically, resilience has emerged as a trait and/or a state. Because of this dualistic approach to analyzing resilience, different scales were developed that operationalized resilience as either a trait or a state. In their recent work, Kuldas and Foody (2022) have called for a transactional approach to define resilience instead of the commonly used dualistic approach [13]. Because higher scores indicated higher resilience in both scales, a combined “composite” score was computed by adding both Trait Resilience Scale and State-Resilience Scale scores.

The questionnaire was assessed for face validity by 4 academicians who were also registered nurses. Before the questionnaire was used in the larger study, the questionnaire was pilot tested among 15 undergraduate nursing students. The test–retest method was used to assess the stability of scores over a short period. The nursing students were asked to complete the questionnaire. After 30 min to 2 h, the same nursing students were asked to complete the questionnaire once again. Scores obtained in both rounds were correlated using Pearson’s correlations. The stability of scores was ensured by a Pearson’s coefficient (r) of > 0.80. In this study, the value of r was 0.90 which indicated excellent stability of scores. The internal consistencies of the items in the State-Resilience Scale and Trait Resilience Scale were assessed using Cronbach’s alpha statistics. A Cronbach’s alpha value of > 0.70 was considered acceptable. In this study, the 18 items in the Trait Resilience Scale had a Cronbach’s alpha of 0.78 and the 15 items in the State-Resilience Scale had a Cronbach’s alpha of 0.77. These values indicated that the items in both scales were internally consistent.

The tool used in this study was a paper-based questionnaire that was distributed to the nursing students by the class representative of each session (academic year). The class representatives were also students who were elected by the other students to represent them in organizing academic and social activities. The participants were informed that participation was voluntary and anonymous as no data relevant to their identity would be collected. The participants were also informed that answering every item was necessary, otherwise, the participants should not return the questionnaire. English is the language of instruction in the nursing programs taught in Palestine. Courses are taught and examinations are held in the English language. Therefore, the questionnaire was originally developed in English. To avoid any confusion, each item was translated into Arabic language. The items were translated by the researchers who were fluent in both Arabic and English. To ensure the accuracy of the translation, forward- and back-translations were used.

The researchers approached the class representatives and explained the objectives of the study to them. The class representatives were provided with additional written information about the objectives and design of the study. The class representatives were asked to invite the other students to participate in this study. Students who expressed willingness to provide informed consent were asked to complete the questionnaire.

The data collected in this study were entered into Statistical Package for the Social Sciences version 21.0 for Windows. Absolute skewness and kurtosis were used to assess the data for the normality of distribution. As the absolute skewness was within the range of -2.0 and + 2.0 and the absolute kurtosis was in the range of -7.0 and + 7.0, the data were considered normally distributed [27, 28]. In this study, the data were expressed as means with their corresponding standard deviation (SD) values. Differences in resilience scores among the nursing students were compared using Student’s t-test. Scores were correlated using Pearson’s correlations. High correlations were indicated by Pearson’s correlation coefficients (r) of ≥ 0.70 and moderate correlations were indicated by 0.50 ≤ r < 0.70 [29]. Multiple linear regression models were used to identify predictors of higher resilience scores and to control for potentially confounding factors. In this study, the variables with a p of < 0.10 in the Student’s t-test were retained in the regression model. Goodness-of-fit was evaluated using the adjusted R-squared (R²) with a p of < 0.05. Durbin-Watson statistics were used to detect autocorrelation problems. Durbin-Watson in the range of 1.5 to 2.5 indicated the absence of autocorrelation issues. The variance inflation factor (VIF) and tolerance values were used to ensure the absence of multicollinearity problems. In this study, tolerance values ≥ 0.25 and VIF values ≤ 2.5 were considered acceptable and indicated the absence of multicollinearity problems [30]. A p of < 0.05 indicated statistical significance.

An-Najah National University's Institutional Review Board (IRB) approved this study. The study was compliant with the Declaration of Helsinki on the ethical principles for human medical research. Participation in this study was completely voluntary. All participants provided informed consent. Data were collected anonymously and no information leading to the identity of the participant was collected in this study.

In this study, 314 undergraduate nursing students were invited by the class representatives. Of those, 290 students completed the questionnaire, giving a response rate of 92.4%. In this study, 129, 72, 71, and 42 students were invited from the first, second, third, and fourth academic year. The response rates were 96.1%, 93.1%, 88.7%, and 85.7%, respectively. About half of the nursing students were male and 62.4% were 20 years and older. The majority (79.7%) of the nursing students were nonsmokers, 73.8% were born and raised in the occupied Palestinian territories, and 74.8% lived in rural areas. Of the nursing students, 53.1% lived with their parents and needed to commute to the university. The vast majority (96.2%) of the students lived with their parents who had their own family house (94.1%). Of the nursing students, 41.4% stated that the house had enough rooms per number of siblings. Of the students, 28.3% stated that their parents attended a university and were able to make some savings. About 1 in every 5 nursing students worked a part-time job, 5.2% had a chronic disease, and 3.4% experienced addiction issues. Of the students, 42.8% were in their first academic year, 61.4% had a GPA of 2 or more, 37.2% had a study routine every day, and 7.9% stayed connected to social media for 9 or more hours per day. Details of the sociodemographic, economic, and academic variables of the nursing students are provided in Table 1.

The mean trait resilience score was 71.4 (SD: 7.5), the mean state resilience score was 62.7 (SD: 6.7), and the mean combined resilience score was 134.1 (SD: 12.8). There was a significant moderate positive correlation between state resilience scores and trait resilience scores (r = 0.63, p < 0.001). The distribution of ratings of the nursing students on the 18-item trait scale and 15-item state resilience scale are shown in Table 2.

The majority of the nursing students reported very high or extreme trait resilience (79.0%) and state resilience (87.6%). The distribution of the students in trait and state resilience categories is shown in Table 3.

The mean trait, state, and combined resilience scores were significantly higher for undergraduate nursing students who lived in Israeli seized areas compared to those who lived in occupied Palestinian territories, reported higher household income compared to those who reported higher household income compared to those who reported lower household income, were in the first academic year compared to those who were in the second-fourth academic year, and reported a study routine on daily basis compared to those who did not report a study routine daily as shown in Table 4. The mean trait and combined resilience scores were significantly higher for undergraduate nursing students who lived in a house with enough rooms per number of siblings compared to those who lived in a house without enough rooms per number of siblings. The mean state and combined resilience scores were significantly higher for undergraduate nursing students who lived in urban areas compared to those who lived in rural areas, did not need to commute to the university compared to those who needed to commute to the university, and those who lived in a dormitory/residence compared to those who did not live in a dormitory/residence. The mean trait scores were significantly higher for undergraduate nursing students who had a university education compared to those who had a school education and those who did not have chronic diseases compared to those who had chronic diseases. Differences in the mean resilience scores are shown in Table 4.

The multiple linear regression models showed that higher trait, state, and combined resilience scores were predicted by having a study routine on daily basis. Trait and combined resilience scores were predicted by the absence of chronic diseases, experiencing addiction issues, living in Israeli seized areas, and living in a house with enough rooms per sibling. On the other hand, state and combined resilience scores were predicted by being in the first academic year and state resilience scores were predicted by living in urban areas. Details of the multiple linear regression analyses are shown in Table 5.

The present study has several strengths and limitations that need to be considered when interpreting the findings. First, this study was the first to assess resilience among nursing students in Palestine. The findings of this study could add to the existing literature on resilience among nursing students worldwide, notably, in developing countries. Second, the study was conducted at the main university in Palestine. The university has a large number of nursing students that contribute to a significant proportion of the future workforce of nurses practicing in Palestine. Third, the sample recruited in this study was diversified in terms of representation of both genders, students in different academic years, from different regions, and socioeconomic classes. This diversity might have improved the external validity of the findings and might allow extrapolation of the findings to the entire population of nursing students in Palestine. Fourth, resilience was assessed as a trait, state, and combined in this study. The tools used to assess resilience were previously validated. Additionally, the tools were revalidated in a pilot test that was conducted before the larger study to ensure the tools were valid and reliable in the study settings.

On the other hand, this study has some limitations. First, the sample size was relatively small. The sample size was calculated using a 90% CI. This limitation could have been avoided if the sample size was calculated using a 95% CI. Second, the nursing students were recruited from one university. Recruiting nursing students from other universities should have strengthened and improved the external validity of the findings. Third, social desirability bias cannot be ruled out in this study. As the nursing students had to rate some of their traits, some students could have overrated their traits. Fourth, we cannot rule out recall bias in this study. As the nursing students had to recall memories of the past, we cannot rule out recall bias in this study. Fifth, 42.8% of the students who responded to the questionnaire were in the first academic year. This could have led to participation bias. Sixth, analysis of the combined resilience scores could be associated with an increased alpha error. Seventh, although resilience is thought to be shaped by the sociodemographic, economic, and academic variables of the nursing students, a causal relationship cannot be proven in this cross-sectional study. Another prospective study should be conducted to see how resilience changes as students advance in their academic years. Nurse educators and other stakeholders are recommended to take into planning how to support nursing students to improve their resilience and transition into their future nursing practice.