Background and Purpose

Nurses face complex stressors in their day-to-day work including routine exposure to human suffering and potentially traumatic events such as violence. Consequently, nurses are at high risk of moral distress, critical incident stress, workplace burnout, and compassion fatigue. Despite common beliefs that adversity is debilitating (Joseph, 2011), the literature finds resilience is the most common outcome following adversity (Bonanno, 2004; Masten, 2001) and is, in fact, the core experience of the majority of people (Galatzer-Levy et al., 2018). This research takes the opportunity to explore resilience in nurses.

In this study, resilience is defined as A system of alternative pathways through adversity or potential trauma; a multidimensional, multileveled, dynamic, and transformative health construct with biological, psychological, cognitive, behavioural, and spiritual/cultural mediators (Blaney, 2017). The phenomenon of resilience has been found to be a contributing factor to mental health—in individuals and communities—following adversity (Masten et al., 2011) and is a mitigating factor for workplace stressors and a predictor of overall mental health (Mental Health Commission of Canada, 2023). Resilience is contextual (Bonanno et al., 2015; Hobfoll et al., 2015; Panter-Brick, 2014), and exploring contextual and cultural concepts is critical in order to broaden the understanding of resilience in nurses.

In previous research with firefighters (Alexander, 2016; Blaney & Brunsden, 2015), “resilience” emerged as an overarching concept when firefighters were discussing coping in the context of work-related traumatic events. Firefighters were found to be resilient (Blaney & Brunsden, 2015) when measured on a resilience scale (Wagnild, 2009); hence, the research team was curious about resilience in other high-intensity professions, such as nursing. Traditionally, the priorities of research with nurses have been on disease outcomes (Health Canada, 2006), leaving gaps in the resilience literature, and raising questions about if and why nurses are resilient (McAllister & Lowe, 2011). This project built education from a resilience theory that was co-created with firefighters (Blaney et al., 2021), adapted it in collaboration with nurses to the healthcare context, and translated resilience theory into nursing practice.

With over 40,000 nurses working in British Columbia, Canada, a strong foundation of resilience is key for nurses to maintain mental health and cope with work-related stressors, in order to provide quality patient care and optimize patient outcomes (McAllister & Lowe, 2011; McAllister & McKinnon, 2009). Resilience and better mental health in nurses are linked to better work performance and safe quality patient care (Havaei et al., 2022; Walpita & Arambepola, 2020). The existing resilience models/approaches define and describe resilience from several disciplines reflecting a variety of epistemologies, ontologies, and methodologies (see, for example, Southwick et al., 2014) but this study considers resilience in nurses as a dynamic, synergistic, transformational system of interconnected pathways through adversity (Blaney, 2017).

Learning about resilience confers protective effects on workers in demanding work settings such as healthcare (Earvolino-Ramirez, 2007); however, the effectiveness of resilience education remains largely unknown with few published studies despite the recent proliferation of resilience training programs such as “Road to Mental Readiness” (R2MR; now titled “The Working Mind”) and “Building Resilience—Tools for thriving in today’s fire rescue service.” Many studies have evaluated these programs, but most have examined outcomes that are not specific to resilience (Fikretoglu et al., 2019; Robertson et al., 2015; Sarkar & Fletcher, 2017). The one study that did examine resilience saw no immediate effects of training, though there were moderate increases in resilience scores 12 months post-training (Carleton et al., 2018). This is in alignment with a recent systematic review and meta-analysis of 25 randomized controlled trials (RCT) of resiliency training programs which concluded that education had small to moderate effects on resilience (Leppin et al., 2014).

There is little literature related to resilience outcomes in nurses, hence the need for education to increase awareness and to enhance nurses’ capacity for resilience. At the time of this writing, there is no published data that represent the experiences of nurses who participate in resilience education; hence, this study provides foundational data for the utility of resilience programs for nurses.

This study explored whether a cohort of nurses was resilient, looked at whether a targeted resilience education program improved nurses’ resilience scores, and if so, were those improvements sustained over time. Using mixed methods and best practices in the design and delivery of a resilience education program, this study addressed the following research questions:

  1. 1.

    Are resilience scores of nurses affected by resilience education?

  2. 2.

    How do nurses understand resilience in the context of their workplace?

  3. 3.

    What role does resilience play in nurses’ mental health?

  4. 4.

    Is single-session targeted resilience education effective in maintaining resilience scores over time (2 months)?

Methods and Procedures

Mixed methods and longitudinal studies are the methods of choice for resilience research (Bonanno & Mancini, 2012; Ungar, 2011). A quasi-experimental design was chosen for this study; all nurses at a local hospital (initial sample), and later, all nurses in the health region regardless of nursing specialty, work unit, or role, were eligible to participate, and there was no randomization or control group. The study utilized quantitative Pre-Ed/Post-Ed methods and a qualitative questionnaire of recent critical events, resilience tools utilized by participants, and personal knowledge about resilience (questionnaires available upon request).

Development of a Resilience Education Program

Knowledge about health and resilience contributes to resilience (McAllister & McKinnon, 2009). Previously, there has been criticism of programs offering resilience education because (a) they do not define the construct and context of resilience; (b) they do not have standardized outcomes or outcome measures; and (c) few models are informed by available research evidence (Mental Health Commission of Canada, 2022); the resilience education program designed for this study meets all of these criteria.

A unique feature of this program was the intentional incorporation of best practices in curriculum design and active learning concepts. Curriculum design began with collaboratively designing learning outcomes (LOs) with a nurse advisory group. The LOs are learner-centered and help to ensure the quality of education, using action verbs that are measurable, observable, and attainable in the given timeframe (Fink, 2003), and utilized the revised Bloom’s taxonomy (Krathwohl, 2002).

Once the outcomes were designed, the curriculum of the resilience education program was framed around four foundational concepts: content, mode of delivery, proactive education, and curriculum congruence with nursing (Sarkar & Fletcher, 2017). As well, principles, concepts, and practices of active learning (Grabinger & Dunlap, 1995) were incorporated into the design and implementation of the curriculum. The curriculum is based on current resilience research and resilience education research (Robertson et al., 2015; Sarkar & Fletcher, 2017) and integrates a novel definition and theory of resilience (Blaney, 2017).

In this study, resilience is defined as A system of alternative pathways through adversity or potential trauma; a multidimensional, multileveled, dynamic, and transformative health construct with biological, psychological, cognitive, behavioural, and spiritual/cultural mediators (Blaney, 2017, p. 137). This definition overarches a model in which six core categories serve as the abutments to the pathways through adversity and help operationalize the definition: Relationships; Personal resources; Meaning-making; Culture; Leadership; and Knowledge (Blaney et al., 2020). This model provides the foundation for the curriculum developed and utilized in this research.

The curriculum content was multimodal incorporating skills, actions, and mindset. For example, the curriculum included mindfulness exercises as one aspect of the resilience model and as actions for maintaining resilience. Another example draws from cognitive-behavioral theory and offers an exercise in positively reframing thinking (Fletcher & Sarkar, 2016).

Initially developed and intended as in-person sessions, due to the global pandemic, the resilience education program was adapted for online synchronous delivery. Education sessions were facilitated by the Principal Investigator (PI) and the research assistants (RAs). The RAs managed the technical aspects of online education (setting breakout rooms; ensuring task instructions were available in the “chat,” etc.). Course handouts and other resilience resources were posted on the PI’s website for future reference and for inclusion in the organization’s psychological health materials/future training.

Tools

Two tools were chosen for pre- and post-testing of resilience scores: the Resilience Scale 25 © (RS) and the Resilience at Work (R@W) Scale. The RS has been shown to be reliable and valid (Wagnild, 2009; Windle et al., 2011). The PI obtained permission to use the scale in this study and has used the scale in other research with firefighters in Canada and the UK. The RS was chosen because it uses positive and health-focused language and focuses specifically on resilience; in contrast, other scales use deficit/disease language (Connor & Davidson, 2003) and often have different foci such as coping (Carver, 1997).

The Resilience at Work (R@W) Scale (Winwood et al., 2013) has also been shown to have reliability and validity (Malik & Garg, 2018), and has been implemented across a variety of organizational settings and roles; this will be the first time it has been used with nurses. This instrument was chosen because it examines resilience capacity (as opposed to deficits or characteristics) and focuses on workplace behaviors.

The qualitative component of this study utilized a third tool, a narrative questionnaire, named the Resilience Questionnaire (RQ). The questionnaire inquires about participants’ demographics as well as perceptions of stress and resilience; the Pre-Ed RQ asks detailed questions about demographics and was then adapted for both Post-Ed questionnaires in order to target identification and retention of learning about resilience. The questionnaire was co-constructed with firefighters (Blaney, 2003) and was adapted for this research in order to capture the cultural phenomenon of nursing. Ungar (2011) notes the need to match contextually and culturally relevant measures with standardized measures such as the RS that capture phenomena that may be invisible to those from outside the culture/context.

Recruitment

The convenience sample for the study was nurses from a regional hospital on Vancouver Island who had previously expressed interest in participating in health research; the hospital employs about 500 nurses (registered nurses, registered psychiatric nurses, licensed practical nurses, and nurse practitioners). Ultimately, nurses who worked in some community programs such as home support as well as nurses from other facilities across the health region also participated.

Nurses were made aware of the resilience education program through various in-house methods such as the Island Health Weekly, an organization-wide electronic newsletter, and email. Managers and unit coordinators were invited to socialize a poster on their unit social media feeds as well as through staff email. The poster outlined the aims of the research project and directed staff to a website for further information including the consent.

Nurses were invited to pre-register for their chosen resilience education program session via an email address developed and monitored by the research assistants; participant email addresses were entered into the REDCap system, and auto-generated emails were sent to participants in advance of the session, immediately following the session, and 2 months post-education.

Once registered in the REDCap system and 3 h prior to the start of the session, the auto-generated email invited participants to complete the three online questionnaires described above, which took approximately 20 min total (Pre-Ed). Upon completion of the consent and questionnaires, participants were given a Zoom link to the online resilience education program (4.5 h of Zoom class). At the end of the course, participants were given a reminder via email and asked to fill out similar questionnaires to those they completed prior to the education (approximately 20 min, Post-Ed). Two months later, participants were contacted by a REDCap auto-generated reminder which asked them to again fill out the questionnaires (2 months Post-Ed). This longitudinal approach allowed the research team to assess if/what participants had retained and/or used from the resilience education program.

The total time participants committed to the project was 5.5 h, and all participants were eligible for employer-paid education time.

Data was transcribed/coded/handled within REDCap and de-identified prior to handling by the research team.

Privacy and Data Storage

The questionnaires and consent were administered through REDCap, a secure web platform used by many agencies worldwide; all REDCap data for this project is stored in Canada. REDCap collects email addresses and matches the Pre-Ed and Post-Ed questionnaire data with the participant, but withheld the participant identification from the researchers so that participant data remained anonymized.

Under the PI’s license for Zoom workshops, Zoom data may be stored outside Canada; however, the PI followed best practices for securing Zoom meetings (for example, pre-meeting settings such as waiting rooms; in-meeting settings such as locking the meeting, etc.).

Quantitative Data Analysis

Quantitative data analysis was provided by the members of the research team from the Department of Mathematics at Vancouver Island University. Statistical analysis was performed using Microsoft Excel and R (an Open Source Statistics Software). A P-value of less than 0.05 was considered statistically significant.

At each of the three stages of the study (Pre-Ed, Post-Ed, and 2 months Post-Ed), participants were invited to submit a questionnaire from which their RS scores (potential range from 25 to 175) and R@W scores (potential range from 0 to 150) were determined. Wagnild’s Resilience Scale User’s Guide (Resilience Scale User’s Guide | the Resilience Center, n.d.) was employed to calculate the RS.

Before testing for differences among the scores across the three stages, homogeneity was tested with respect to the demographic variables (i.e., age, gender, length of service, etc.). Homogeneity was assessed by comparing median RS scores using the Kruskal-Wallis non-parametric test.

For statistical analysis, only participants who completed all three questionnaires were included so a repeated measures approach could be applied. Since data among the three groups (Pre-Ed, Post-Ed, 2 months Post-Ed) were not normally distributed, the non-parametric Friedman rank sum test was used to test for differences among these three groups, first for RS scores, then for R@W.

Qualitative Data Analysis

Qualitative methods in this project included content and thematic analysis (TA) (Braun & Clarke, 2006; Windle et al., 2011) in order to generate practice-relevant outcomes. TA is a method of systematically identifying, analyzing, organizing, describing, and reporting themes found within a data set; TA is intended to generate knowledge in a rigorous and methodical way and is the method of choice when we are looking for clear descriptions of resilience in nursing (Windle et al., 2011).

In order to ensure trustworthiness, the qualitative data was subjected to Nowell et al.’s (2017) six-phase model; although the model may appear to be linear, the researchers utilized reflective and iterative processes and moved back and forth through the data and phases (Nowell et al., 2017).

Data analysis began after the transcription of the first few education sessions. In the first phase, the PI transcribed the de-identified data into Word documents and then shared them with the project co-lead and the RA’s for individual engagement with the data and gross content analysis; each team member then subjected the data to thematic analysis (Maguire & Delahunt, 2017; Vaismoradi et al., 2013) using Braun and Clarke’s framework (Braun & Clarke, 2006). All identifying information was removed from transcripts and field notes in order to maintain the anonymity of participants.

The researchers (except the statisticians) independently read and reread the transcripts, wrote notes, and developed preliminary codes, then began looking for relationships within the data (Thorne et al., 2016). Through this concentrated attention, the data was organized by each researcher into categories with similar patterns. A thematic analysis table was utilized to explore the themes as they were discovered. This process of analysis required continued immersion in the data and included monthly and then biweekly discussions with the research team to discuss the processes of coding and theming in order to uphold the validity of the study. Throughout this process, the PI maintained a reflexive journal for the purpose of bracketing throughout the project (Tufford & Newman, 2012).

Once each researcher had extracted their themes, the team met as a whole to compare themes, and to combine interpretations of the data. The categories were linked back to the research questions and were reviewed and reinforced through dialogue between the PI and Ras that was founded on “how does this category relate to the research questions?” Throughout the analysis process, the findings were organized and reorganized to explore the descriptions and experiences as described by nurses.

Qualitative Analysis and Bloom’s Taxonomy

In order to assess the effectiveness of education, the data was further subjected to the revised Bloom’s taxonomy (Krathwohl, 2002), a framework used to align learning outcomes with progression in learning. Bloom’s taxonomy is used to define and distinguish higher-order thinking and complex learning. In this project, the use of the taxonomy offered insights into the effectiveness and applicability of the resilience education program.

Post-education language from the immediate Post-Ed and 2-month Post-Ed questionnaires was compared with the language of the Pre-Ed narrative data of the RQ by subjecting the data to thematic analysis against Bloom’s taxonomy. Again, Bloom’s provided a framework for examining the progression of learning by comparing words that are indicative of lower levels of learning (i.e., the use of verbs such as ‘remember’) from the pre-education data with words that are reflective of higher levels of learning (i.e., “adapting,” “designing,” “discussing”) from post-education data.

Results

Resilience Education Program

In total, the resilience education program was delivered nine times between April and August 2021. At each session, there were between 8 and 16 attendees; some were participating in the research and some were not. The research team had a list of workshop attendees but the PI and co-lead did not know who participated in the research or who the questionnaire responses were coming from.

The sample size was intended to be 100 participants. The final sample size was 98 nurses who participated in the resilience education program, with 74 completing the Pre-Ed questionnaires. The sample is representative of nurses who fulfill similar roles, experience similar stressors such as nursing during public health emergencies and workload/staff shortage, and routinely face exposure to potentially traumatic events (PTEs) and other hazards inherent in the job (participant demographics available upon request).

Quantitative Data Analysis

RS and R@W Scores

At each of the three stages of the study (Pre-Ed, Post-Ed, and 2 months Post-Ed), participants were invited to submit a questionnaire from which their RS scores (potential range from 25 to 175) and R@W scores (potential range from 0 to 150) were determined. Of the 74 participants who filled out the Pre-Ed questionnaire, 55 (74%) returned the Post-Ed questionnaire, and 21 (28%) returned the 2-month Post-Ed questionnaire. For statistical analysis, only the 21 participants who completed all three questionnaires were included so a repeated measures approach could be applied.

Are Resilience Scores of Nurses Affected by Resilience Education?

To determine if the resilience education program had a significant impact on RS scores both immediately after the education (Post-Ed) and longer term (2 months Post-Ed), we used the Friedman test. This test determined statistically significant differences among the Pre-Ed, Post-Ed, and 2-month Post-Ed RS scores (P = 0.0005). Post hoc analysis showed statistically significant increases in median RS scores between Pre-Ed and Post-Ed (P = 0.0028) and Pre-Ed and 2 months Post-Ed (P = 0.0246), but did not show a statistically significant difference between Post-Ed and 2-month Post-Ed groups (P = 0.2047; Table 1).

Table 1 Comparison of RS and R@W Scores on Pre-Ed, Post-Ed, and 2-month Post-Ed questionnaires (n = 21). At each of the three stages of the study (Pre-Ed, Post-Ed, and 2 months Post-Ed), participants were invited to submit a questionnaire from which their RS scores (potential range from 25 to 175) or R@W scores (potential range from 0 to 150) were determined. Analysis for RS scores and R@W scores was performed separately. In both sets, data among the three groups were not normally distributed, so the non-parametric Friedman rank sum test was used to test for differences. A P-value of less than 0.05 was considered statistically significant
Full size table

To determine if resilience education had a significant impact on R@W scores immediately post-education (Post-Ed) and longer term (2 months Post-Ed), the Friedman test was used, but no significant differences were detected (P = 0.06335; Table 1).

Qualitative Data Analysis

In addition to answering questions from which RS and R@W scores were determined, the RQ asked participants to provide demographic information and information related to the work environment. A number of key dimensions or themes emerged from the narrative data in each of the Pre-Ed, Post-Ed, and 2-month Post-Ed questionnaires. These were organized based on three of the research questions posed in this study:

  1. 2.

    How do nurses understand resilience in the context of their workplace? (Table 2)

  2. 3.

    What role does resilience play in nurses’ mental health? (Table 3)

  3. 4.

    Is single-session targeted resilience education effective for building and maintaining resilience? (Fig. 1)

Table 2 How do nurses understand resilience in the context of their workplace? A summary of themes with examples, and links to Bloom’s revised taxonomy. Data was collected from the nine resilience education sessions that were conducted throughout this study (April–August 2021)
Full size table
Table 3 What role does resilience play in nurses’ mental health? An analysis of the tools and strategies used and learned through education, and how they are applied. A summary of themes with examples, and a link to Bloom’s revised taxonomy. Data was collected from the nine resilience education sessions that were conducted throughout this study (April–August 2021)
Full size table
Fig. 1
figure 1

A selection of posters created by participant groups during the targeted resilience education program highlighting the key components of resilience. These posters demonstrate the “spread” of knowledge from the individual nurses to their colleagues and beyond. Designed by research participant teams April–August 2021

Full size image

How Do Nurses Understand Resilience in the Context of Their Workplace?

The thematic analysis of participants’ definitions and experiences with resilience yielded four themes characterizing a wide variety of experiences: return to normal, essential skills and abilities, innate traits, and digging deep. Overall, the themes highlight the complexity of nurses’ experiences with resilience, and demonstrate the increased depth and breadth of nurses’ overall understanding of resilience (beyond the definition) in the pre- and post-education definitions. These themes are summarized with examples of the analyzed data and the links to Bloom’s revised taxonomy in Table 2. The Post-Ed themes showed greater depth and breadth of nurses’ understanding of resilience. The immediate Post-Ed themes recognized the “process” of resilience as follows: pathways, dynamic and adaptive, self-efficacious, knowledge, and growth. Data from the 2-month Post-Ed questionnaires repeated these themes and built on them with an increase in emotive language (i.e., “transcending the struggle”) and a shift from deficit language to strengths-based language (i.e., “challenge,” “adapting,” “health,” etc.) thereby reinforcing the evidence of deeper comprehension of the concept of resilience.

What Role Does Resilience Play in Nurses’ Mental Health?

Analysis of data related to strategies produced six themes that are congruent with previous resilience research (Blaney et al., 2020) and are aligned with Bloom’s revised taxonomy (Table 3). The cumulative data were indicative of participants’ strategic use of evolving actions or activities to assist in building and maintaining resilience. Strategies from the Pre-Ed data are physical, emotional, cognitive, behavioral, and spiritual in nature, and also reflect personal attributes such as compassion, pragmatism, and gratitude. The immediate Post-Ed strategies include the Pre-Ed resources but have additional themes reflecting the core categories within the resilience model, along with an articulation of the value of the “community” of nurses within the nursing unit. The 2-month Post-Ed data showed even greater depth and breadth, and aligned into four new themes of strategies to build resilience: the role of self-regulation (i.e., focusing on strengths, letting go of stressors, etc.); the role of culture (i.e., peer support, positive work culture, etc.); the power of gaining new strategies or more “tools in the toolbox” (i.e., mindfulness; attitude change, new knowledge); and frequent practice of strategies (more regular attendance at the gym; consistent practice of emotional regulation, etc.). There was also a clear articulation of how various strategies were being applied; use of language such as the following: “more consistent [self-care],” “still doing it,” “actively changing the culture,” “talking more about [resilience] on my unit,” “talking to my family about [healthy eating, self-care…] illustrating the translation of knowledge to the individual nurse and also the spread of this knowledge to colleagues and family.”

Is Single-Session Targeted Resilience Education Effective for Building and Maintaining Resilience?

Towards the end of each education session, participants were randomly placed in teams of three or four, and invited to create an education poster for their colleagues who were unable to attend resilience education. Each team was given one or two categories of resilience (as per the resilience model that was presented during the education program) such as relationships, personal resources, meaning-making, culture, leadership, and knowledge. Participants were invited to present, in any format, some aspect of the resilience category that had resonated with them and which they felt was important for their workmates to know about. This was a time-limited exercise that required participants to rapidly organize themselves, choose a format, choose and articulate specific knowledge that resonated with them, and present their posters to the other teams. In the Post-Ed questionnaires, participants noted that this exercise “helped solidify” what they learned, assisted in “talking about resilience” in meaningful ways, shared perspectives among team members, and “hearing how others are going to use what we learned.” Examples of posters demonstrate the “spread” of knowledge from the individual nurses to their colleagues and beyond (Fig. 1).

Using learners’ own words on the Pre-Ed questionnaire (i.e., “remember,” “understand,” “memorize”) and juxtaposing their words in the two Post-Ed questionnaires (i.e., “analyze,” “value,” “design,” “create”), it was determined that the language of the Post-Ed questionnaires was congruent with Bloom’s conceptualization of deeper learning as the mastery of skills and ideas (Tables 2 and 3). For example, “developing defenses” was an example of a Pre-Ed experience of resilience but Post-Ed language gave credence to broader emotional reactions and strategies (i.e., resilience was defined as “processing emotions”; “using healthy ways to get beyond negativity”). Also, before the education session, participants defined resilience in somewhat simplistic, single-dimensional language (“bounce back”) whereas following education resilience was defined in more complex terms reflecting the complexity of the construct (“always in motion, always changing,” “looks different in everyone,” “multiple pathways not just a continuum”).

In addition, triangulating the Pre-Ed and Post-Ed data with the narrative language in the quotes from the in-session value discussion and the posters created by participants (Fig. 1) offered further evidence of deep learning. Finally, the shift in learner language pre- and post- to more complex language (Smith & Colby, 2007) demonstrates that this education effectively provides “significant learning.”

Serendipitous Findings

Several serendipitous findings surfaced during data analysis and through informal discussions when the PI and co-lead encountered nurses at various worksites. Nurses reported that they and their colleagues are talking more frequently and more in-depth about mental health and resilience; this is reportedly most evident during quieter times on-shift when healthcare teams are together and focused, but it has also been noted when members are talking outside of work. At least seven nurses independently and spontaneously sought out the PI to report that they are also practicing mindfulness and reframing negative thoughts, and feel more comfortable talking about mental health with work colleagues as well as friends and family. These reports are noteworthy in that they reinforce that knowledge is retained and is being applied.

Another theme that surfaced during the chance encounters in the hospital was that eight nurses reported they are now viewing critical incidents as opportunities for post-traumatic growth, a concept that had been introduced during the resilience education sessions and is in keeping with positive psychology.

Nurses in this study also expressed discomfort with the political and social designation of nurses as “heroes.” During the in-session discussions about values and, again, during spontaneous hallway chats, participants talked about the hero myth (Lewis et al., 1999). These nurses acknowledged that the public may need heroes and idols during times of duress but noted “[we] plug along day after day” living our values and “showing up” each shift despite the inherent challenges of nursing work; this is seen not as heroism but as humanism. Paradoxically, the public’s creation of “an epic tale of strength and valor” (Lewis et al., 1999) starring nurses ultimately disparages the professionalism, knowledge, and skill of day-to-day nursing work.

Discussion

This study utilized a novel resilience education program that was delivered online to 98 nurses. Data was collected through Pre-Ed, Post-Ed, and 2-month Post-Ed questionnaires, which aimed to answer the following questions:

  1. 1.

    Are resilience scores of nurses affected by resilience education?

  2. 2.

    How do nurses understand resilience in the context of their workplace?

  3. 3.

    What role does resilience play in nurses’ mental health?

  4. 4.

    Is single-session targeted resilience education effective in maintaining resilience scores over time (2 months)?

Targeted Resilience Education Increases Nurse’s Resilience Scores on the Resilience Scale

This study found that nurses have moderately high baseline RS scores prior to any interventions (Wagnild, 2009). Participating in a resilience education program increased resilience (as measured by the RS), immediately following the education, and this increase was sustained 2 months post-education (Table 1). A trend towards an increase in R@W score was also observed following the completion of the resilience education program; however, this increase was not statistically significant, likely due to the small sample size (n = 21). The sustained increase in resilience scores was further supported by the qualitative data describing the type and frequency of self-identified resilience strategies (Table 1, Table 2).

There is limited literature about resilience education where the variable of interest is resilience score; much of the existing literature measures outcomes such as wellness, mental health awareness, or mental illness. Carleton et al. (2018) demonstrated that resilience scores (measured with the Brief Resilience Scale rather than the RS and R@W) of law enforcement personnel show no change immediately after education but those scores do increase at 12 months post-education (Carleton et al., 2018). In contrast, our findings show a statistically significant increase immediately following intervention which is sustained 2 months post-intervention. This finding is consistent with the recent work of Sarkar and Fletcher (2017) who study resilience in high-performance athletes. There are similarities between nurses and other first responders (Blaney et al., 2020) and elite athletes in that these populations perform in high-intensity and pressurized situations. Future research is needed to examine longitudinal data from the RS and R@W with nurses as well as across other first responder populations.

Nurses Understand Resilience in the Context of Their Workplace, and This Understanding Is Strengthened by Single-Session Targeted Resilience Education

The curriculum design for the targeted resilience education program was intentional, collaborative, and contextualized to nurses. The four foundational concepts for resilience education (content, mode of delivery, proactive education, and curriculum relevance to the audience) described by Sarkar and Fletcher (2017) were obvious contributors to the effectiveness of the learning session. Course content had been co-created by nurses and was based on a theory and model of resilience that was co-developed by the PI with firefighters (Blaney, 2017). The model and definition resonated with nurses by using a visual that was understandable yet demonstrated the complexity and dynamism of the construct. Participants described resilience as “messy” in contrast to the more common depiction of resilience as a basic continuum but said they were able to see more “possibilities in the mess” to influence their own resilience.

Resilience Plays a Role in Nurses’ Mental Health, and Targeted Resilience Education Provides Strategies for Growth and Reframing

Nurses in this study have a wide array of health strategies for maintaining their resilience that were further enhanced through experiential education. The qualitative data from this study indicated that nurses strategically use evolving actions or activities to assist in building and maintaining resilience. This was clear in Pre-Ed data and became more apparent in Post-Ed data where there was a clear articulation of how various strategies were being applied. Of note, the benefits of this education were not only impacting the nurses who participated—participants were sharing strategies with colleagues and family as well.

Single-Session Targeted Resilience Education Is Effective for Building and Maintaining Resilience

The resilience education program was proactive, using principles of health promotion and positive psychology to reframe critical incidents from being “overwhelming” to being challenges (Sarkar & Fletcher, 2017) with multiple pathways for navigating common and expected stress reactions. Integrating real-world nursing examples or challenges into the classroom required participants to collaborate in small groups, consolidate their knowledge to make decisions in the moment, report to other groups, and discuss their rationale for their outcomes/solutions to the challenges; this in turn allowed theory to come alive for participants and contributed to significant learning. In summary, principles and best practices of adult learning, combined with a multimodal nurse-specific resilience curriculum, were key contributors to the participants’ in-depth learning.

Knowledge about resilience, particularly the depth and breadth of participant definitions, changed substantially after the education sessions; this knowledge was maintained at 2 months post-education, contributing to the conclusion that the resilience education had sustained positive effects. This conclusion is bolstered by other data such as the changes in scores on the RS and the R@W Scale.

The serendipitous findings from this study are also important in that they indicate the effectiveness of resilience education in evolving the thinking and practices of nurses, and also highlight the need for further longitudinal research into resilience in other healthcare personnel. Importantly, specific research into the aspects of individual nurses’ resilience that influences organizational resilience is necessary; individual resilience is positively associated with organizational resilience but the mechanisms are not well understood (Liang & Cao, 2021) and nurses in this study stated they are keen to contribute to overall work culture and organizational resilience. As well, the study reinforces the reality of nurses as strong, knowledgeable, competent professionals thereby offering an alternative to the social sketch of nurses as damaged heroes (Mohammed et al., 2021).

Study Limitations

The qualitative results of this study are robust and consistent with the limited research on resilience in first responders; however, the sample size is relatively small which may impact the generalizability of the findings. The number of participants was likely heavily influenced by the impact of the dual public health crises (the COVID-19 pandemic and the poisoned drug crisis) which has led to widespread staff shortages. Future research with nurses should include wide geographic representation, heterogeneity of the participants, and a larger sample size.

Resilience in the Organizational Context

Resilience education must be part of a broad psychological wellness program that includes skills development, moral resilience, flourishing, post-traumatic growth, and other upscaling to the foundational resilience curriculum. As highlighted in the recent “Recover to Rebuild” report released by the International Council of Nurses, individual resilience is not enough; in the context of regrowing, recovering, and rebuilding the nursing workforce post-pandemic, there is a strident call for systematic organization and employer response in order to avoid further burden being placed on individual nurses to be “resilient” as they come through a fourth year of the pandemic and rebuild (Buchan & Catton, 2023). Traynor criticizes nursing resilience studies and interventions for operating under a “tacit acknowledgement [that] the workplace experienced by nurses is so dysfunctional that it is better to invest energy in devising personal approaches to coping than investigating or challenging the causes of dysfunction.” (Traynor, 2017, p, 12). It is past time to reframe burnout as an organizational and collective phenomenon and to hold organizations, as opposed to the individual worker, accountable for worker well-being. This important mindset must be adopted, and corresponding systemic changes must be enacted. It is not enough to have resilient nurses—many of the challenges facing nurses in the current healthcare context are system-level and require system-level solutions (Bryant & Hinkley, 2021) that include relevant policies and procedures and improved working conditions, alongside programs that support individual resilience and overall wellness.

Conclusion

The important and unique findings of this mixed methods study contribute to the literature, impact the evolving discourse on resilience and resilience education, and offer a counter-narrative to the media and social reports of rampant mental illness and suicidality among nurses (Crowe et al., 2022; Stelnicki et al., 2020) through the finding that the nurses in this study are resilient. The targeted resilience education program used in this study led to increased resilience scores immediately following the education session, and these increases were sustained for a period of at least 2 months.

Higher resilience scores are correlated with better mental health, better job performance, and higher job retention. Higher levels of resilience are also associated with increased hope, reduced stress, and decreased vulnerability to burnout (Rees et al., 2016; Rushton et al., 2015; Walpita & Arambepola, 2020). Nurses in this study expressed values of personal agency, service to others, hope despite adversity, and pride in their work. Their resilience scores confirm that nurses have strengths and capacities that can be harnessed to support themselves, their colleagues, their patients, and the organization.

This study shows that resilience can be improved through education suggesting that resilience may be an actionable target to improve nurses’ overall well-being. Resilience confers protective mechanisms despite ongoing workplace stressors (Shatté et al., 2017) and must be supported organizationally and personally. We believe that it is imperative that all student nurses be provided with resilience education in preparation for entry to practice, and there must be ongoing upscaling of this education for nurses and other healthcare providers in all health organizations.