1. Theoretical stage
1.1. Dictionary meaning of the resilience of nursing staff in nursing homes
According to the American Heritage Dictionary [19], resilience is defined as “The ability to recover quickly from illness, change, or misfortune, buoyancy. The property of a material that enables it to resume its original shape or position after being bent, stretched, or compressed; elasticity.” As for NHs, they are defined as “a private establishment that provides living quarters and care for chronically ill, usually elderly patients” [19]. Nursing staff refers to personnel who provide nursing care in NHs and in South Korea is composed of nurses, nursing assistants, and care workers [20,21]. Thus, the resilience of NH nursing staff can be defined as the ability and process by which NH nursing staff quickly recover from the negative experiences experienced while working in a NH and return to their daily activities and work duties.
1.2. Dimensions, attributes, and measurements in the theoretical stage
- Dimensions In the theoretical stage, the concept’s dimensions were confirmed through a literature analysis as “personal adversity management ability,” “a dynamic process of positively adapting through adversity,” and “maintaining psychological/social health.”
1) Personal adversity management ability: In this dimension, resilience is regarded as an individual's unique characteristics and abilities in the process of coping with adversities. Resilience has been described as the ability to achieve successful adaptation in the face of high-risk conditions, chronic stress, or subsequent trauma [22], as well as the ability to sustain a functional life [23]. Werner and Smith [24] defined it as the ability to recover from adversity, while Conner and Davidson [25] defined it as the ability to successfully cope with stress and adversity. Resilience has also been described as the ability to find psychological stability and balance in the face of severe stress or unavoidable difficulties [26], the ability to achieve successful adaptation in the face of danger, stress, and trauma [22], and the effort to restore or maintain personal balance and mental and physical health. A comprehensive examination of the above definitions finds that this dimension emphasizes personal competence, strength, and the ability to overcome stress or trauma and achieve successful adaptation to difficult situations.
2) A dynamic process of positively adapting through adversity: Margalit [27] defined resilience as a dynamic process of positive adaptation experienced through adversity, while Windle [28] defined it as a process of effectively regulating, adapting, and managing the underlying factors of stress and trauma. Similarly, Dyer and Mcguinness [29] described it as the process by which humans deal with adversity and continue with their lives, and Garcia-Dia et al. [30] described it as a dynamic process of recovering from adversity. As such, resilience in this dimension refers to the series of processes involved in experiencing, recovering from, and adapting to adversity.
3) Maintaining psychological/social health: Kander [26] defined resilience as finding psychological stability in the face of severe stress or unavoidable difficulties, and Bonanno [31] defined it as maintaining stable, continuous mental and physical health. This refers to maintaining one’s psychological and social health after the process of overcoming and adapting to the underlying factors of stress and trauma. Resilience in this dimension means ultimately overcoming stress and trauma, returning to daily life, and living a stable life.
- Attributes The attributes identified at the theoretical stage were adaptability, interpersonal relationships, flexibility, persistence, self-regulation, positivity, self-care, and self-esteem.
- Measurements The Connor-Davidson Resilience Scale is a self-rated assessment that measures a person’s sense of control and tenacity, self-efficacy, tolerance of negative affect and ease of recovery, positive acceptance of change, and secure relations. Friborg et al.’s Resilience Scale for Adults [32] is a 37-item scale that measures personal and social competence, family coherence, social support, and personal structure. The Wagnild & Young Resilience Scale [33], derived from a qualitative study of older women (aged 67-92), measures equality, perseverance, self-reliance, meaningfulness, and existential aloneness, while Rahman et al.’s Medical Professionals Resilience Scale [34] measures control, involvement, resourcefulness, and growth. From a holistic understanding of the above scales, when measuring resilience in nursing, self-belief, dependable relationships, resources for support, willingness to grow, management of stress, positivity, and flexible thinking were identified as indicators by which to measure resilience.
1.3. Working definition
The working definition of NH nursing staff resilience refers to the entire process of maintaining psychological/social health while undergoing a dynamic process of positively adapting through adversity with the personal crisis management ability to overcome crises in stressful or emergency situations.
2. Fieldwork stage
The general characteristics of the participants are presented in table 1. As a result of analyzing the collected interview data, the three dimensions of emotional stability, bonding with colleagues, and coping with situations, and the seven attributes of optimism, patience, mindfulness, empathy with colleagues, cooperation with colleagues, setting work boundaries, and self-development were derived.
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2.1. Emotional stability
This dimension refers to overcoming adversities through emotional stability. Three attributes are included in this dimension: optimism, patience, and mindfulness. This dimension centers on maintaining a positive perspective by acknowledging and accepting various situations through emotional stability.
“I think everything is a matter of my heart (mindfulness). If I take good care of my mind, everything is supposed to work out (Optimism).” (Case 2)
“People these days think it's a problem because they're too impatient. Even if difficult things happen, you need to have a little patience (Patience).” (Case 4)
2.2. Bonding with colleagues
In the second dimension, the bond with colleagues is the driving force for overcoming the crisis. This dimension includes the attributes of empathy and cooperation with colleagues.
“Caring for a dementia patient is really hard. Only my colleagues can empathize with this situation (Empathy with colleagues).” (Case 6)
“When the workload is too much, the nurses or nursing assistants I work with help me, and I try to help them (Cooperation with colleagues).” (Case 7)
2.3. Coping with various situations
The third dimension focuses on overcoming crises by actively responding to difficult situations. This dimension includes the attributes of work-life boundary setting, self-development, and growth.
“The most important thing is to have personal time. I try to forget everything by getting away from work and getting enough rest, both physically and mentally (Work-life boundary setting).” (Case 3)
“Even in difficult situations, if I move forward toward the future instead of staying in the present, I can have vitality in my life (Self-development, Growth).” (Case 5)
3. Final analytical stage
As a result of the final analysis, the attributes, dimensions, indicators, antecedents, consequences, related concepts, and types of resilience were identified (Table 2). All participants showed all the attributes and indicators of resilience examined in the final analysis, but in this study, the intensity of the attribute and indicator of each case was analyzed based on the interview contents, and the conceptual structure was schematized based on the results (Figure 1).
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3.1. Attributes, dimensions, and indicators
The attributes, dimensions, and indicators of the resilience of NH nursing staff were analyzed while comparing the literature analysis and fieldwork stage results. That analysis and comparison confirmed optimism, patience, mindfulness, supportive relationships, available resources, work-life boundary setting, self-development, and growth as the final attributes of NH nursing staff resilience. The dimensions identified in the final analysis stage were internal resources, external support, and positive coping with difficult situations. As a result of comprehensively analyzing the indicators, NH nursing staff were classified into three types: those who want to adapt themselves to the situation, those who actively seek to cope with stressful situations, and those who have positive expectations for the future.
3.2. Antecedents
The antecedents of resilience can be divided into psychological and situational problems. The psychological problems found to be experienced by NH nursing staff were job stress, mental disorders, burnout, and role stressors. Their situational problems were traumatic situations, staff shortages, unsatisfactory work environments, shift work, and uncooperative patients and caregivers.
3.3. Consequences
The consequences of resilience can be broadly divided into two parts: improvement of individual nurse's mental health and improvement of work-related life. The improvement of individual nurses’ mental health resulted in mental disorder reduction, increased quality of life, adaptation, and situational self-control. The improvement of their work-related lives led to developing insights into their roles as nurses, reducing work stress, providing a higher quality of care to their patients, and increased job satisfaction.
3.4. Related concepts
Through the theoretical and fieldwork stages, we were able to find both similar and contrary concepts. The ability to use judgment, make good decisions, and perceive change as beneficial when faced with the stressful challenges of life is called hardiness [35,36]. Nurses with hardiness are more likely to be committed to the job, experience less burnout, and are less likely to give up or resign [37]. As such, hardiness and resilience have similar meanings as both reflect internal characteristics that buffer the negative effects of stress and play an important role in personal well-being and psychological sustainability [38]. However, hardiness develops early in life and is regarded as part of an individual's personality traits and dispositions, and strength is also regarded as dispositional resilience [39]. Thus, hardiness has a similar but more limited meaning than resilience.
The contrary concept is burnout, which includes physical and emotional fatigue and stress due to stressful situations, which can result in an individual quitting work [40]. This concept includes both physical and psychological symptoms, and can lead to anger, irritability, and a negative attitude toward one’s job, finally resulting in resignation [41]. Burnout has a meaning contrary to that of resilience and is also viewed as an antecedent factor.
3.5. Types of nursing home nursing staff resilience
The types were categorized by CASEs (each participant) that appeared strongly in the indicator, and the strength of the attribute was also considered (Table 1). Based on the results of the analysis, the resilience of NH nursing staff was divided into three types. The three types are those who seek to adapt themselves to the situation, those who want to cope with a stressful situation, and those who have positive expectations for the future. The researchers found that when categorizing types, internal strength and dependence on external resources became important axes; hence, the types were categorized in three directions based on those two axes. It is possible to increase the clarity of the concept together with Wilson's conceptual analysis method [17,18]. Model cases that fully exhibit the attributes and indicators of the resilience concept is presented by type below.
1. Type Ⅰ. Those who seek to adapt themselves to the situation
This type is willing to accept the situation they are facing, maintains a positive attitude, and has a flexible mind. In addition, this type tries to overcome crises by adapting themselves to the situation and has a strong tendency to solve problems using their internal resources. This type of characteristic was well demonstrated in Cases 1, 2, and 4.
() : attribute; [ ] : indicator
Case 1 is a nurse in her 40s who has been working in a NH for fifteen years. Case 1 well demonstrated her ability to overcome crises through her emotional stability but expressed that she felt most frustrated when caregivers did not trust the nurse and complained frequently. Meaningful statements from her include: "All the answers are in my mind. When I try to look at a situation in a positive way, it flows positively" (Optimism) [Positive attitude in everything]. "I work with elderly people, so it takes a lot of waiting. Difficult situations arise, but I don't respond to every situation. I don't care about things I can't control. Often the problem is solved by waiting" (Patience) [Flexible way of thinking]. “As I think about the goals of my life as a nurse, I try to look objectively at what is bothering me. I meditate every morning and try to look at it objectively, repeatedly reminding myself of the things that are bothering me” (Mindfulness) [Having a clear goal].
2. Type Ⅱ. Those who actively seek to cope with stressful situations
This type sought to cope with stressful situation by using the resources available to them. This type tried to reduce stress by using one’s own strategies and was actively helped by relying on close relationships. They tried to solve the problems they faced by using these active methods. Cases 6 and 7 demonstrated these characteristics well.
Case 6 is a nursing assistant in her 30s who has been working at a NH for eight years. She had a difficult time receiving constant complaints from a resident's family due to the recent resident's pressure sores. But she tried to cope with the difficult situation quickly. Meaningful statements from her include: "I received a lot of comfort from my colleagues. All my colleagues enjoy good relationships and support each other in difficult times. We always take good care of each other and get along well" (Supportive relationships) [Smooth interpersonal relationships]. "I have a lot of people to get help from. The manager of this NH is always interested in us and gives us vacation time when we look tired” (Available resources). “On my days off, I usually travel" (Work-life boundary setting) [Relieving stress].
3. Type Ⅲ. Those who hold positive expectations for the future
This type focuses on work by clarifying the scope of their work and striving to develop themselves. Through these efforts, they seek to grow step by step and to cultivate positive expectations for the future. Positive expectations for the future are the source of their strength to overcome crises. Cases 3 and 5 showed the characteristics of this type well.
Case 3 was a nursing assistant in her 30s who had worked for five years in a NH. She explained that the stress at her job was bothering her, even when she returned home from her job. Case 3 exemplifies overcoming her crisis by coping with her situation. She told us the following: "I couldn't stand being bothered at home because of the stress of work. So, when I got home, I put my phone on silent and tried not to think about work. I instead tried to get enough rest, meet friends, and forget about work” (Setting the boundaries of work) [Relieving stress]. I felt that I had to understand the elderly well to be able to do my job effectively, so I voluntarily searched for education related to elderly care, studied it, and tried to accumulate knowledge. In the future, I want to become a senior nursing specialist and provide professional nursing care” (Self-development, Growth) [Receptive attitude to challenges, Having a clear goal].
3.6. Conceptual structure
From the derived results, the relationship between dimension, attribute, and type could be expressed as shown in Figure 1, focusing on the characteristics strongly expressed in the concept. Each attribute belonging to the three types is organically connected to constitute the concept of resilience. In the case of type 1, the attribute belonging to the internal resources dimension was emphasized, and in the case of type 2, the attribute belonging to external support was prominent. In the case of type 3, it was found that many attributes of coping with the situation were expressed. Considering both indicator and attribute, the type could be expressed with inner strength and dependence on external resources as axes.