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

Aim To understand nurse resilience by integrating the qualitative research results on nurses’ resilience-related experiences. Methods We applied the seven steps of the meta-ethnographic process by Noblit and Hare (1988). Five databases (PubMed, EMBASE, Web of Science, CINAHL and PsycINFO) were used to search for relevant studies published from January 2011 to September 2021. Results Sixteen qualitative studies were included. The four themes of “self-development based on one’s inner self”, “fostering a positive attitude towards life”, “developing personal strategies for overcoming adversity” and “building professionalism to become a better nurse” illustrate that they want to improve their inner strength and develop themselves through self-examination. Conclusion In this study, we examined nurse resilience, and the results can provide fundamental conclusions useful for the development of an intervention study to improve nurse resilience. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-021-00803-z.


Introduction
Nurses are the largest occupational group in the medical health field. They account for approximately 59% of the total global medical health workforce [1], and play a very important role in patient care. Globally, in recent years the nursing profession has been a rapidly growing sector of the workforce [2]. However, nurses suffer stress and burnout related to their job, and this has a very negative effect on their mental health [3]. Problems that negatively affect the mental health of nurses can have serious consequences, such as decreased nursing professionalism, poor quality of care, increased social and financial losses, and increased turnover and resignation [4,5].
Nurse job satisfaction has been in decline over recent years, and nurses have been found to develop negative perceptions about their job [2]. Nurse job satisfaction is related to the turnover rate, which affects the quality of patient nursing care. As concern over nurse job satisfaction and burnout is increasing worldwide [6], timely studies of concepts that can ameliorate the negative job perceptions of nurses caused by their negative experiences are required.
Resilience is a positive concept that allows nurses to overcome stressful situations [7] and to adapt positively, resulting in the maintenance of their psychological wellbeing and mental health [8,9]. In a recent study, nurse resilience was found to significantly reduced nurse burnout [10,11]. Resilience is emerging as an important concept for reducing the psychological burden of nurses and increasing their physical and mental health, since resilience has been shown to have a mediating effect on the relationship between burn out and physical/mental health [12]. Recently an understanding of an individual's culture is considered very important for understanding resilience [13], so when exploring resilience in nurses, a key occupational group in society, we need to pay attention to their culture.

Background
Most people have life-threatening experiences or are exposed to one or more stressors in their lifetime [14]. Therefore, it is very important to improve and adapt mental health to aid recovery from the challenges and adversities one faces and to adapt positively. Since nurses in particular are exposed to wide-ranging stresses, the ability to overcome such adversity is particularly important for them. The concept of resilience originated in psychology [15,16] and can be described as an individual's characteristics, processes, and outcomes [15].
According to Ungar [17], studying resilience requires a contextualized approach because the dynamic partnerships between individuals and social ecosystems can lead to positive adaptation when individuals face difficulties. Given this perspective, the issue of culture is very important, and exploring resilience in the context of the culture to which nurses belong can help to properly identify the dynamic property of resilience nurses. An understanding of resilience can be effectively applied to improving the mental well-being of nurses.
Research into nursing resilience has been steadily improving, and over the last 10 years the importance of the concept of resilience has become emphasized as related research has rapidly increased. In particular, resilience has been proposed as a solution to burn out [10,11,18] and mental health issues [19,20], which nurses frequently suffer from, and related research has been actively conducted.
Nurse resilience contains a complex and dynamic process that changes over time and according to the situation, embodying not only personal attributes but also external resources, and describes a nurse's ability to adapt positively to stress and adversity [21].
Academic interest in nurse resilience has been increasing recently, and many qualitative studies are being conducted to explore the essence of nurse resilience. However, the diversity of these qualitative studies and the differences in their findings has hindered understanding of the core concepts of nurse resilience.
Qualitative meta-synthesis is a methodology for synthesizing and analyzing individual qualitative research [22]. This methodology is recognized as a useful tool for analyzing the meaning, experience, and perspectives that participants' express [22]. It can help accumulate knowledge and derive expanded knowledge and new interpretations from the the areas of research and phenomena suggested by the results of existing studies [23]. The methodology also enables more specific suggestions for future studies [22].
Noblit and Hare developed one of meta-synthesis method, meta-ethnography in 1988 [24]. This method has the potential to lower study duplication, create new research questions, and promote higher-level analyses [25].
In this study, the results of qualitative studies on nurse resilience are integrated, a new interpretations are attempted. This study will help provide fundamental information for the research and development of interventions to improve nurse resilience. The purpose of this study was to systematically review and synthesize the qualitative evidence on the nurse resilience experience.

Aim
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.

Design
We used a meta-synthesis methodology, which provides broad understandings of social phenomena, to integrate the findings of qualitative studies [26]. Since metaethnography 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 metaethnography 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: 1. "How do nurses overcome adversity?" 2. "What are the characteristics of nurses resilience experiences?" This review was prepared in accordance with ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research Statement) guidelines [28]. This metasynthesis study was registered (CRD42021275787) with PROSPERO, which is the International Register of Systematic Reviews.

Search methods
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).

Quality appraisal
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). Phase 3. Reading the studies & Phase 4. Determining how the studies are put together.

Data extraction
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.
Phase 5. Translating the studies into one another, Phase 6. Synthesizing the translations & Phase 7. Expressing the synthesis.

Data synthesis
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 'firstorder 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.

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

Results
Sixteen qualitative studies were included in this review study and the publication years of the included studies were from 2012 to 2021. A total of 241 nurses participated in the included reviewed studies. Their ages varied widely, from those in their 20s to those in their 60s, and they were generally of female gender. Their working departments were varied, and included the ICU, the geriatric ward, the emergency room, the psychiatric ward, and the general ward. The studies were conducted in Africa, Australia, Canada, Iran, Japan, Singapore, Taiwan, USA, and UK. In other words the studies were conducted in various countries around the world (Table 1). This study yielded four comprehensive themes of nurse resilience experience. These were 'self-development based on one's inner self', 'fostering a positive attitude towards life, 'developing personal strategies for overcoming adversity', 'building professionalism to become a better nurse'. Table 2 shows the key concepts from the first-order constructs, the second order constructs, and the synthesized themes.
Theme I. Self-development based on one's inner self 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 "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).

Sub-theme 2. Striving to develop oneself
Rather than despair, the nurses wanted to grow on their own. They tried to maintain their physical health "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).

Theme II. Fostering a positive attitude towards life
In theme 2, the sub-themes included "accepting life positively" and "enjoying their own life". In this theme, the power of nurse positivity is evident. The nurses showed that they were trying to overcome adversity with positivity. ""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). "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).

Theme III. Developing personal strategies for overcoming adversity
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 wideranging human relationships. These methods of overcoming adversity were their own individual strategies learned through their own experiences.

Sub-theme 5. Staying away from stress
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 "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). "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 sometimesa laughs the best waywe 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).

Theme IV. Building professionalism to become a better nurse
In theme 4, the sub-themes "planning their life for a better future" and "building self-esteem by thinking about the value of a job" were included. The nurses planned their future to live a better life than just leaving their lives to adversity. They felt that they had to develop themselves for a better future, prepare for a new life, and adapt to a new situation. They thought they had to rearrange their work by considering their priorities. This process led them to build their professionalism. "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).
Sub-theme 8. "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).

Discussion
As nurses play a very important role in the medical field, they are exposed to wide-ranging difficulties because of the high intensity of their work. Research on the resilience of nurses, a positive force to overcome this, has recently attracted attention in both research and practice. This study synthesized the result of qualitative research on nurse resilience to explore nurse experiences of overcoming adversity.
According to the result of this study, when nurses felt that they were going through a difficult situation, they tried to recognize and acknowledge that situation by exploring their inner selves. They focused on themselves and tried to find out exactly what their situation and problems were through self-exploration and not evading issues. This can be thought of as a preparation process for problem solving. In the context of the more general resilience attributes found by previous studies, it can be noted that the nurse attributes discovered by this study, such as a belief in self-efficacy and a desire to improve oneself, are aspects of resilience in general [34]. In addition, the results of this study can support the results of previous studies that internal protection factors such as self-efficacy, optimism, emotional intelligence and self-management should be covered in the training of resilient nurses [35].
However, nurse resilience included striving for selfdevelopment while focusing on reality. These results show that nurses in a crisis situation have a strong tendency to rapidly grasp problems, trust themselves and solve problems quickly. Also, the nurses showed that they wanted to solve problems and grow step by step rather than remaining in crisis. The subjects of this study were incumbent nurses in their 20s to 60s, including relatively young subjects, and it likely that the specific nature of the active and developmental results derived in this study reflect all of them having the profession of nursing in common.
Nurses tried to overcome adversity by accepting life positively and enjoying their own lives. In previous studies, this positivity property as a component of resilience was found to be universal across varied subjects, as a part of the concept of general resilience [33,36] and the resilience of chronic disease patients [37]. In addition, nurses showed the characteristics of wanting to be challenged in life and enjoy the life given to them. This can be seen as showing an active attitude to life, and, since nurses are generally made up of healthy young people, this showed a different aspect of resilience from those shown by patients who are highly dependent on their families and medical staff [37,38]. A positive and active attitude towards life could be an important factor to focus on in the development of future intervention research aiming to improve nurse resilience.
Nurses exhibited the resilience characteristics of avoiding stress and separating their lives from stress when overcoming adversity. They showed that they were trying to overcome adversity by guaranteeing the quality of their own lives. This characteristic results from the professional stress of a nurse, reflects the substantial stress they face at work, and is something we should pay attention to. The results of this study can support the findings of previous studies that nurses recognized work-life separation as a very important factor when considering resilience [39]. Nurses got comfort from wide-ranging human relationships. The human relationships of nurses were characterized by wanting to develop their relationships between colleagues to an intimate level, particularly friendship, and them securing comfort from these relationships with such close colleagues. Considering these characteristics of nurse resilience shows the need when developing future intervention studies to improve nurse resilience to create resilience programs that consider peer relationships.
As the nurses overcame adversity, they try to adapt themselves by developing themselves and preparing for new situations. They try to organize their lives while arranging work priorities. Nurses tried to overcome adversity by planning for the future and developing one step at a time. In addition, in the face of adversity they took pride in being nurses by reflecting on why they chose their profession and reminding themselves of its value. By raising their job satisfaction and passion for their work, their self-esteem was also raised. They wanted to grow further as nurses by constantly exploring and developing job-related knowledge and skills, and tried to overcome the difficult situations they faced through the process of growth. The aspect of resilience, that contains the meaning of growth, has been revealed in previous studies [40]. However, the resilience of nurses has more specific meanings than the previous concept of resilience in that nurses plan for a better future, value the professional meaning of nursing, and want to develop as nurses. This characteristics of the resilience of nurses who plan for the future in difficult situations and want to develop themselves further can suggest a direction for intervention research to enhance nurse resilience.
Due to the COVID-19 pandemic of recent years, many medical staff, including nurses, are struggling in the medical field. Several studies have been published that show that, in some countries, facing this difficult situation has lowered the resilience of nurses [41,42]. Resilience is the strength to overcome such crisis situations, and the importance of the ability of nurses to overcome these global medical crises is increasingly being emphasized [43]. Many studies have emphasized the need for intervention research to improve nurse resilience [44]. The results of this study can provide fundamental data on what factors to focus on when developing intervention studies to improve nurse resilience, which has been lowered in the pandemic situation. We need to focus on the inner self and plan interventions that will improve that aspect. Also, interventions that rebuild positive strength and allow nurses to overcome adversity and grow individually will be very helpful for them to overcome adversity. These varied approaches can be expected to give positive strength to nurses, particularly in the currently challenging medical field.
This study helps the understanding of resilience in nursing, and provides an appropriate lens for a contextualized approach to resilience research. This is very meaningful data from a socio-ecological point of view and emphasizes the importance of interactions between individuals and society [17], and is expected to ultimately play a positive role in the development of society.
This study has two strengths. First, the included studies are from very diverse countries, such as the United States, Japan, Australia, South Africa, the United Kingdom, Canada, Singapore, Iran, and Taiwan, reflecting studies of various cultures. Therefore, this study can provide universal knowledge that is applicable worldwide. Second, of the literature used in this study, all 16 articles were found to satisfy the quality evaluation criteria by 70% or more, so the study is based on an analysis of relatively high quality documents of wellorganized structure.
Despite these strengths, this study has limitations. The nurses included in the literature were from wide-ranging sub-fields, and the specific stress characteristics of the particular departments were not reflected in the result. Therefore, in the future, conducting qualitative research on the resilience of nurses across nursing sub-fields is suggested. To resolve this, meta-synthesis studies could be conducted to elucidate the characteristics of nurses within more specific fields.

Future research
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].

Conclusion
Emphasizing resilience, a positive force for overcoming adversity, to nurses can play a very significant role in improving the quality of nursing care. In this study, nurses showed resilience to grow and develop themselves by focusing on their inner selves and finding ways to solve problems on their own. These can be considered as categories of nurse resilience and provide a framework to guide the development of an intervention program for improving nurse resilience. Based on the results of this study, to improve the quality of nursing care we should try to develop varied intervention programs that enhance nurses' inner strength.