The aim of this study was to evaluate the effect of written information and counselling by an APN on resilience in women with vulvar neoplasia three and six months after surgery. Additionally, we investigated the influence of social support, age, counselling time and local recurrence on resilience in this population. The results showed no significant difference in resilience between the two intervention arms. Furthermore, the findings indicated that social support, longer counselling time and higher age were associated with a higher resilience score, whereas local recurrence was associated with a lower resilience score. The six-month period was found to have no influence on resilience.
To our knowledge, this is the first study to explore the effect of information-related interventions on resilience in women with vulvar neoplasia. One explanation for the non-significant results could be that the benefit of the intervention could be noticeable at a later time and more time could be needed for adaptation, probably due to the dynamic process of resilience . A study of a recently published review investigated data over an average five-year period .
The results may indicate that a single intervention, such as counselling by an APN to improve symptom management, is not sufficient to promote resilience. This would be in contrast to the conclusion of Haase , who suggested that specific factors (e.g. illness-related factors) can be used to promote resilience. This implies that multimodal interventions are necessary to facilitate resilience in cancer care. A possible multimodal intervention could be based on the adolescent resilience model by Haase . The theory involves various factors, such as illness-related, family, social and individual factors. This theory could be particularly interesting for younger women with vulvar neoplasia. A more holistic model is the society-to-cells model described by Szanton et al. . This model includes factors at the cellular, physiological, individual, family and society levels and should be particularly used for nursing intervention to facilitate resilience.
The results could also indicate that the intervention period should be extended, i.e. counselling should offered directly after the diagnosis. A recent review revealed that interventions provided immediately after the diagnosis and in parallel with somatic treatment had the greatest effect on resilience . Therefore, a multiprofessional approach should be considered. Adequate information about diagnosis and treatment, e.g. fertility preservation or preservation of sexual function, seems to be as important as the treatment of symptoms post-operatively in women with vulvar neoplasia [27, 28]. Various reviews have stated that an individualised approach should be used for surgical treatment, especially in patients with advanced disease. Additionally, more conservative and less radical surgery and the new reconstructive plastic techniques have been associated with lesser physical and psychological morbidity [5, 6].
The results of the linear mixed models reveal that resilience was positively associated with age. Previous studies on individuals with colorectal cancer and the general population support our result that older age is associated with higher resilience [29, 30].
One explanation of this result is that older women have already completed family planning or can look back on a fulfilled life. Thus, they probably have less emotional distress and can better accept the situation . For women of childbearing age, the fact that they cannot have children may be worse than the diagnosis itself . This can lead to an additional stressor in younger women, and more time and support would therefore be needed for successful adjustment. Therefore, it should be noted that younger women show more psychosocial symptoms than older women .
The present study revealed that resilience is positively associated with a longer counselling time. This result is in line with the finding by Ludolph et al. . They found, in a review that the greatest effect strength is achieved with a longer intervention duration, i.e. more than 12 sessions and a cumulative duration of at least 24 h.
The WOMAN PRO program was based on the self-management concept. One of five core-self-management skills is problem solving. Here, the problem defined by the patient is considered specifically, and the patient is guided to find the most suitable solution . Therefore, it can be assumed that a longer counselling time contributes to resolving disease-related uncertainties and developing effective problem-solving strategies  and supports to cope successfully with symptom-related distress. This assumption is confirmed by a qualitative study, where women reported that they felt safe and secure because they were more confident after the APN actively took time to talk to them and discuss their concerns .
At this point it should be emphasized that regular quality controls were carried out for this study. The result can be an indication of appropriate quality of counselling and standard of care.
Interestingly, our results indicated that the impact of counselling time decreases with increasing age. Older individuals have possibly been confronted with other adverse circumstances (e.g. previous illnesses, divorce or the death of a loved one), resulting in positive problem-solving strategies ; hence, lesser support or information may be required. On the other hand, older women may have more difficulty talking about their symptoms. A previous study mentions that older women are particularly ashamed to talk about their disease .
We found that a higher level of perceived social support predicts higher resilience. This result is not surprising; previous studies confirm the buffering effect of social support [34, 35]. Qualitative studies have indicated that social support, especially for patients with taboo diseases, such as vulvar neoplasia, is important to successfully cope with the situation. It allows talking about the experience and contributes to reduced stress and higher emotional well-being [32, 36].
Social support can be from different sources, such as family, friends or other important persons . APNs or nurses can play an important role in encouraging women to speak about cancer, request assistance or minimise prejudices. Kobleder et al.  have described that women felt more secure and less alone in the experience of their illness after having the possibility of contacting an APN.
Finally, the present findings reveal that resilience is negatively correlated with recurrent disease. In a descriptive study, Dubey et al.  showed that resilience in patients with different types of cancer does not correlate with recurrence. Recurrence possibly promotes hopelessness and leads to lower resilience  as well as fear and uncertainty about the further course of the disease .
This study has several limitations. First, the reduced sample size may lead to a loss of accuracy and, under certain circumstances, statistical significance. Additionally, the described drop-out rate could have an impact on the validity of the study, however, participants who dropped out did not differ significantly compared to those who completed the study. Extended data collection was not possible because of the limited study resources
Second, this study did not account for potential confounders, such as time since the cancer diagnosis or other sociodemographic variables (e.g. education and marriage). Further, some participants might have experienced other types of traumatic events that were not assessed.
Third, participants with mental disorders were excluded, thereby increasing the risk of bias, as resilience correlates with different mental disorders, e.g. depression or anxiety .
Finally, the short duration of the study did not allow for assessing the long-term effect of the intervention on the development of resilience.