The ability of older people to overcome adversity: A review of the resilience concept
This is the peer reviewed author accepted manuscript (post print) version of a published work that appeared in final form in: Van Kessel, Anna Gisela Maria 2013 'The ability of older people to overcome adversity: A review of the resilience concept' Geriatric nursing, vol. 34, no. 2, pp. 122-127 This un-copyedited output may not exactly replicate the final published authoritative version for which the publisher owns copyright. It is not the copy of record. This output may be used for noncommercial purposes. The final definitive published version (version of record) is available at: https://doi.org/10.1016/j.gerinurse.2012.12.011 Persistent link to the Research Outputs Repository record: http://researchoutputs.unisa.edu.au/1959.8/125780
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Title page The ability of older people to overcome adversity: A review of the resilience concept
Please send correspondence to the sole author:
Gisela van Kessel Centre for Allied Health Evidence City East campus University of South Australia Adelaide, South Australia
[email protected] Phone + 61 8 8302 2551 Fax:= 61 8 8302 2853
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Abstract (147 words) Resilience has been recognised as the ability to bounce back from adversity and regain health. This review seeks to explore the validity of the current understanding of resilience as it applies to older people and its application as guide for interventions. One mixed method, 19 qualitative and 22 quantitative papers were located through a systematic search of nine databases. Results confirmed a number of themes of personal resources. Older people who have the ability to use personal resources and see the world beyond their own concerns are more likely to be resilient. In addition a number of environmental factors were identified including social support from community, family and professionals as well as access to care, availability of resources and the influence of social policy and societal responses. Nurses can facilitate resilience of older people by maintaining or enhancing social support and facilitating access to care and resources. Key words older adults, psychological resilience, well-being, concept, social support
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The ability of older people to overcome adversity: A review of the resilience concept
Introduction Using resilience as a lens to reflect on practice can support nurses and researchers to take a salutogenic approach to health. Antonovsky’s salutogenic model describes a move away from an exclusive disease orientation towards a health promotion approach that encourages the use of personal and environmental resources for maintaining health.
1
The use of resilience to
implement a salutogenic approach can support nurses to actualise a commitment to the goals of health promotion and wellness by enhancing their ability to impact on factors that may increase the resilience of populations. 2 A focus on older people adds to this strengths-based approach by directing attention to the enabling factors elicited from the knowledge and experience of older people. Thus, an awareness of resilience as it applies to older people, enables a health promotion approach to advocate and influence enhanced health outcomes.
What is resilience? There are numerous conceptualizations of resilience from many different disciplines, all conveying their own nuances. Psychological resilience in a broad sense is defined as “a process whereby people bounce back from adversity and go on with their lives”
3
(p. 227).
Individual resilience has been categorised into different types including health, physiological, emotional, dispositional and psychological.
4
These understandings of resilience are
underpinned by a number of theoretical explanations including developmental theory from observations with resilience in children and theories on the psychology of coping and the physiology of stress. 5 Resilience is thought to be a dynamic process within each individual, changing over time in response to life experiences. 6 A substantial number of characteristics of the individual associated with resilience have been established (see the work of Polk for an extensive review).
7
There is also an increasing body of work identifying environmental
resources such as access to care 8,9 availability of resources 9 and the actions of professionals
5
9,10
as influential to the experience of resilience. The dynamic process of resilience may
involve the negotiation and navigation of these internal and external resources.
11,12
Alternatively, resilience is understood as a process of adaptation when challenged by an adversity.
12
However, much of the concept development has been dominated by
investigating middle aged adults with a specific disease process, or children, so there is some ambiguity regarding the validity of the concept for older people.
To have utility, concepts should identify key features of the social world and are “an idea that is expressed in words” 13 (p. 111). Turner suggests that concepts need to be defined precisely to direct researchers to the same phenomenon 14 (p. 5). When the conceptualization of an idea remains ambiguous there is an incomplete set of operational definitions, leading to a lack in clarity regarding what will have to change to produce a different result. Designing interventions for older people that support their resilience relies on conceptual and operational clarity. One way to foster this, is to sensitize the concept through a process which refines it meaning, reshaping and identifying the common aspects within a diversity of others features 13 (p. 118-9).
The resilience concept has under gone a number of sensitising processes.
2,3,15,16
However,
apart from one early study in 1990, 12 empirical resilience research in older people appears to have commenced around 2000. This relatively recent body of research has not been incorporated into these reviews. Thus, previous concept analyses have been founded predominately on a body of research in children. There has been some research into conceptualising resilience in older people but this has been done on a specific sample of
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women over 85. 7,12 Previous conceptualisations have drawn on the researchers own findings 12
or inductively from the experience of clinicians and researchers 7 or narrative reviews. 2,3,16
A systematic review is an alternative method of summarising current evidence to facillate the transfer of knowledge to nurses and increase their confidence in the concept of resilience for use in management and practice with older people. 17,18
The aim of this paper is to facilitate the transfer of current research findings into practice through a systematic search of the literature. The paper defines resilience in older people and summarises findings of elements of resilience with validity for older people, to provide nurses with a framework for identifying older people with lower potential for resilience, recognising specific adversities and implementing interventions to strengthen resilience.
Method Search procedure A database search was conducted using Ageline, PsychArticles, PsychInfo, Psychological and Behavioural Sciences collection, CINAHL Sociological abstracts Medline and Web of Science from inception to February 2012. Search terms included truncation of resilience, with the use of the Boolean operator AND between later life OR elder (with truncation) OR older. Reference lists were screened for further publications.
Selection criteria Publications needed to meet the criteria that participants were over the age of 50 and were based on a definition or theory of resilience. All languages and all empirical forms of publications were considered. A process of screening titles, abstracts and full texts was used
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to exclude publications if they did not meet inclusion criteria. Papers were also excluded if a proxy for resilience was used e.g. well-being or resilience appeared as a conclusion and explanation for a method which used other variables and theoretical frameworks.
Analyses A data extraction form was developed to record identification features, study characteristics, participant characteristics, definitions and findings. Sources were examined for possible influences such as historical, international and author discipline patterns.
Hsieh and Shannon suggest that a summative content analysis can be conducted to explore word usage and discover the range of meanings that resilience has in academic use.
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Analysing the definitions of resilience consisted of identifying and quantifying words and then analysing the use of the words. 19 Word frequency counts in the definition used by each study were calculated using NVivo 9.
Quantitative data was extracted and subjected to a descriptive statistical analysis. Qualitative data was explored with a directed content analysis, which can be used to validate or extend a concept. 19 The directed content analysis used a deductive process to identify key elements to be used as the initial coding categories
19
from the initial themes by Wagnild and Young.
12
The author then highlighted text in the qualitative papers and this highlighted text was then allocated to the predetermined codes. The text that could not be categorised into the predetermined codes was given a new code. The new codes were then reported as emerging themes. The trustworthiness of the analysis was established through the table of results which
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enabled an audit trail back to the original studies. The qualitative and quantitative findings are synthesised in the discussion.
Results Results of the search A total of 142 possibly relevant articles were found after duplicates were removed. Screening excluded 100 articles on the basis of not investigating resilience empirically, exploring resilience of other populations, not peer reviewed and not containing data about definitions and measurement. The remaining 42 articles are dominated by western research particularly USA and UK based. Researchers were represented by the disciplines of medicine, psychiatry and social work but there was a bias towards nursing and psychology. Participants were predominately Caucasian and female. One mixed method study, 19 qualitative and 22 quantitative papers were included.
Resilience Definitions Two key elements of resilience were identified: ability (n = 16) and adversity (n = 14). Adversity was not consistently identified but where it was, it included experience of being old (n = 7), poor health (n = 7), bereavement (n = 6), retirement (n = 2), dying (n = 2), living in a rural setting (n = 2) and one each related to experiencing disaster, identifying as indigenous, being a woman, experiencing poverty, transitioning from hospital and working as a maid. In all papers, including the qualitative literature, the nature of the adversity was determined by the research question. Other common ideas that appeared in definitions used to frame the included research were life, individual, adaptation, bounce, capacity, personality, physical, process, protective and psychological.
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Qualitative findings Twenty papers utilised a qualitative method. This included one mixed method design.
20
Methods used included interview (n = 15) case study (n = 3), storytelling (n = 1) and timeline analysis (n = 1). Fourteen studies were based in the USA with two each in the UK and Sweden and one each in the Netherlands and New Zealand. Six studies explored the meaning given to resilience by women only 7,12,21-24 while only one study explored the experiences of exclusively of men. 25
The body of qualitative research confirms the original themes by Wagnild and Young equanimity,
8,22,26,27
meaningfulness.
self-reliance,
12,20,25,30
7,20,21,23,27,28
existential aloneness,
26
perseverance
12
29
of
and
These themes were used to develop the Resilience Scale but it was
ten years later when the body of research into resilience and older people began in earnest. Fifty per cent of qualitative research into the resilience of older people has been conducted in the last three years.
A meta-synthesis of qualitative descriptions (Table 1) extracted from the papers in this review not only confirmed the original themes from Wagnild and Young 12 but also identified some additional themes. These are categorised Table 1 as internal factors to the individual and environmental factors of influence beyond the direct control of the older person. The role of spirituality dominated the new themes. referred to as generativity,
8,9,27,32,33
9,21,23,26,30-32
Orientation to the future, sometimes
life experience with adversity or hardship,
7,9,24,26
and
caring for others and experiencing giving 7,8,22,32 were other themes new to the seminal work of Wagnild and Young. 12
10
Environmental factors concentrated particularly around the availability of social support from the community, family and professional levels. It featured a connectedness between older people and their community as well as positive relationships with family and friends and empowering relationships with professionals.
7-9,20,21,25,31-34
The ability to access care
7,8
and
the influence on social policy, societal responses and availability of resources were all recognised as influential to the experience of resilience. 8
Quantitative Findings Twenty-three papers used a quantitative method (including the one mixed methods utilised in the qualitative analysis.
20
The focus was either to measure resilience or to establish
correlations between resilience and other factors. A number of studies used different health scales to determine resilience. Resnick et al.
4
35-39
Seven studies use the Resilience Scale,
45
12
and is a 25 item scale with a
Three studies used the Hardy-Gill Resilience scale which has also been
developed with older people and has nine items with a range of 0-9. Resilience Scale,
while
used a modified 14 item version. The Resilience Scale is based on the
qualitative themes described above by Wagnild and Young range of 25-175.
20,40-45
47
4, 6, 46
the Connor-Davidson Resilience Scale (CD_RISC),
48
The Ego –
the Physical
Resilience Scale 4 and the Resilience Appraisal Scale 49 were each used once while one study used their own measure.
49
Scales were interpreted in terms of tertiles so that a score above
147 in the Resilience Scale and 6 in the Hardy-Gill Resilience scale represented high resilience. A review of resilience in older people using the Resilience Scale found a mean of 145.7 and a Hardy-Gill Resilience scale mean of 4.7 indicating older people are capable of moderate resilience over all (Tables 2 and 3). Resilience scales not specially designed for older people reported scores in the top tertile (Table 3).
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Thirteen papers reported factors which demonstrated a correlation with resilience (Table 4). These included self-rated, oral, physical and mental health, cognitive function, problem solving, life satisfaction, well-being, perceived stressfulness of event, sense of coherence, sense of purpose, self-transcendence, positive emotions, optimism, spiritual growth and social support. 6,36,37,40,41,43-49,51,52
Discussion Through a systematic review of research with older people a pattern emerges of resilience defined as the ability to bounce back and recover physical and psychological health in the face of adversity. This definition contains two key constructs, that of adversity and ability.
The experience of adversity underpins the majority of definitions used to frame the research. However, it is the researcher’s interest that appears to dictate the nature of the adversities examined in this review. Only one study asked older people to identify adverse events which the authors then categorised into personal illness, death or illness of a person close to them and non- medical events such as victimisation or changing residence.
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The adversities
investigated tended to be ongoing life experiences rather than specific event such as the experience of being old dying.
9,34
4,8,20,26,30,49,50
or suffering poor health
4,27,29,36,40,44,53
or the process of
Other life experiences framed as adverse included working as a maid in the deep
South of the USA or coming from a minority or disadvantaged group. 21,31,45 Very few studies framed adversity as a defined event such as bereavement,
25,35,38,39,47,53
Hurricane Katrina,
33
or transition from hospital. 32 Events which may be highly significant to older people such as a sudden increase in care requirements or the relocation to residential care are not
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represented. Furthermore, while life experiences of hardship are identified as an internal factor for resilience the influence of particular adversities such as war or disaster during the life span is not well understood.
Ability is the other key term identified in the definitions of resilience. This places the sphere of action within the realm of the older person. Ability may be dependent on other key elements identified such as personality and the skills required to adapt to different circumstances created by adversity. Qualitative findings suggest that factors internal to the older person such as sense of their own ability,
7,12,20,21,23,27,28
their ability to accept their
circumstances, 8,22,26,27 their ability to look to the future 8,9,27,32,33 and care for or give to others 7,8,22,32
are important dimensions of resilience. Quantitative findings suggest that ability to
manage emotions and solve problems influence the capacity of older people to overcome adversity.
36,47,49
The importance of the ability to draw on spiritual strength is supported by
both qualitative and quantitative research 9,21,23,26,30-32,36 but is not consistently featured within resilience measures.
Ability may be further enhanced by health status as evidenced by the correlation between health and resilience. Physical and psychological health occurred frequently in definitions and this is justified by demonstrated moderate correlation of self-rated and mental health 36,41,45
although physical health showed a weaker relationship. 41,43,48
Although earlier research underpinned by personality and developmental theories focussed on the aspects of an older person that might explain their resilience, subsequent research draws
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on sociological understandings that resilience is context dependent. Environmental factors beyond the direct control of the older person within society and care delivery systems play a part. Social support in particular has been identified through both quantitative and qualitative research findings. The social inclusion or isolation of an older person and their ability to maintain effective relationships appear to be critical to the ability to recover from adversity. 36,37,41,48
Nurses can enhance outcomes by understanding the role that their own relationships
plays as well as encouraging social inclusion and connectedness of patients deemed to be experiencing adversity through appropriate referral and linkage. For example residential care managers could consider programmes that maintain connections with families and local communities such as providing internet communications. Managers can also use resilience as a framework to evaluate aspects of care access and resource allocation.
However it may be that before a resilience framework can used to inform the design of interventions targeting the manipulation of either internal or external factors more needs to be understood about the nature of adversity. Further qualitative research seeking insights from older people with different experiences exploring what they perceive to be an adversity for example transitions which are stressful such as hospital or residential care admissions and discharges. In the meantime, nurses can identify the presence of a person’s internal abilities and support independent decision making where this is appropriate. When personal abilities are assessed as limited, it may be more appropriate to support the linkages with family and community. Conversely the resilience framework provides another way to identify older people at risk of not recovering from an adverse event. In particular patients who have difficulty working through their problems, are pessimistic, seem to a have given up, who appear to lack a sense of life purpose or satisfaction and who are socially isolated may be at
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greater risk of being unable to bounce back to premorbid physical and mental health when experiencing a negative event in their life and require targeted interventions. Another gap appears to be an understanding of the influence or not of the physical environment. Given the social environment has strong support across the literature it may be that the physical environment also exerts an influence on the capacity of older people to be resilient. There is potential for research to explore the relationships between neighbourhood features such as local parks, adequate footpaths with social connectedness of older people and resilience. Another example of the possible influence of the physical environment might be the residential care facility infrastructure’s ability to support spiritual events. There is a limited understanding of the influence of other characteristics such as sex, age, ethnicity, race, class, income, education, geographic location, level of exposure and so on. Many studies recorded some of these features but few conducted analyses to determine correlations with resilience. Where analyses have been conducted they are often contradictory due to differences in sampling. Windle et al.
54
and Hildon et al.
old are more resilient than the old old while Netuveli et al. with age. Similarly Wagnild
45
37
35
establish that the young
found that resilience increases
found one sample demonstrated higher resilience in those on
higher income while the other sample did not. This review established that research to date has a bias towards female Caucasian subjects. The mean resilience of older people as predominantly defined by this group is moderately high. What is not known from the literature is the prevalence of high and low resilience for older people as a more heterogeneous group. Comparative analyses based on age could test the theory that resilience is explained by the inoculation theory, that life experience and increased opportunities for exposure inoculates the individual against adverse outcomes in response to stressful events.
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Similarly exploring the presence of gender differences and subsequent explanations may add depth to the utility of the construct.
Future resilience research should be based on a clear operational definition of resilience and therefore the basis of measurement. Not all resilience measures are the same. The two scales specially designed for older people report moderate levels of resilience while scales developed on other populations demonstrate high levels of resilience within older cohorts. This may be because some measure related constructs such as hardiness (CD_RISC), while others are based on the understanding of resilience as a personality (Resilience Scale; CD_RISC) while others are developed on an understanding of resilience as a process (HardyGill Resilience Scale). There is also a bias towards the use of the Resilience Scale which was developed over 20 years ago on a different generation of older people and does not incorporate some of the additional findings from recent research. Future prevalence studies should consider how well the chosen measurement tool incorporates the theoretical construct of resilience. This review is limited by the challenge of finding relevant articles on the psychological reliance of older people in amongst literature on resilience which spans many disciplines and a tendency to use resilience to summarise findings based on other theories and variables so the search strategy relied heavily on screening titles and psychology databases which may have reduced its scope.
Conclusion Resilience in older people can be defined as the ability to bounce back and recover physical and psychological health in the face of adversity. Older people who have a sense of their own
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abilities and in particular exhibit the ability to manage their, emotions, solve problems, draw on spirituality, accept their circumstances, look to the future or care for others are more likely to be able to demonstrate resilience. Nurses can reflect on how their interactions and services maintain or enhance the social support of their clients. Conflict of Interest None
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Table 1. Factors of resilience in older people – qualitative themes Internal factors caring for self /self -reliance/independence/self management/self -efficacy
Emlet et al. 2011; Van Wormer et al. 2011; Aléx 2010; Browne et al. 2009; Kinsel 2005; Felten and Hall 2001; Wagnild and Young 1990
spirituality
Wiles et al. 2012; Aléx and Lundman 2011; Van Wormer et al. 2011; Grandbois 2009; Esche and Tanner 2005; Kinsel 2005; Nakashima and Canada 2005
orientation to the future/moving forward with life/curiosity/ever seeking/choosing survival/will to live/anticipating on future losses/ generativity
Emlet et al. 2011 Janssen et al. 2011; Greene 2007; Esche and Tanner 2005; Nakashima and Canada 2005
Life experiences with adversity (frailty, hardship)
Aléx and Lundman 2011 ; Nakashima and Canada 2005; Felten and Hall 2001; Felten 2000
meaningfulness /purpose in life
Wiles et al. 2012 ; Aléx 2010, Bennett 2010; Wagnild and Young 1990
caring for others/extending self to others, power of giving
Janssen et al. 2011 ; Dorfman et al. 2009; Esche and Tanner 2005; Felten and Hall 2001
acceptance/acceptance and openness about one’s vulnerability/self-acceptance
Aléx and Lundman 2011; Emlet et al. 2011; Janssen et al. 2011; Dorfman et al. 2009
Environmental factors social support
Wiles et al. 2012; Dorfman et al. 2009
supportive relationships of care/empowering relations with professionals
Janssen et al. 2011; Nakashima and Canada 2005
social connectedness/community bonding/ participating in relationship
Van Wormer et al. 2011; Aléx 2010; Bennett 2010; Grandbois 2009; Greene 2007; Esche and Tanner 2005
family/friends support/positive family relationships
Janssen et al. 2011 ; Greene 2007; NelsonBecker 2006; Felten and Hall 2001
ability to access care
Janssen et al. 2011; Felten and Hall 2001
social policy
Janssen et al. 2011
societal responses
Janssen et al. 2011
21
availability of resources
Janssen et al. 2011
22
Table 2. Mean Resilience Scale Score for older adults (n=1554) Source
Wagnild 2003
Leppert et al. 2005 Nygren et al. 2005
Wells 2009 Windle et al. 2008 Aléx 2010 Martins et al. 2011 total
Sample
Resilience Scale
(n=)
mean
43 (low income)
141.2
176 (high income)
147.8
161(low income)
149.1
232 (high income)
148.8
112 (low income)
142.9
599 (53.6% women) 117
132.57 148
22.17 16.0
86 (women)
148
16.9
39 (men)
150
13.7
106 (54% women)
149.4
18.2
Not reported Not reported Not reported 145.7
SD
23
Table 3. Other resilience scale outcomes for older adults (n = 2319)
Source
Fortes et al. 2009
Hardy et al. 2004
Mehta et al. 2008 Resnick et al. 2011
Lamond et al. 2008 Gooding et al. 2012
Sample (n=) 86 (78 % women) 546 (64% women) 105 127 (80% women)
1395 women 60 (58% women)
Scale
mean
SD
tertile
Modified Brazilian instrument
84.9/100
7.2
top
Hardy–Gill Resilience
4.71/9
1.53
middle
Hardy–Gill Resilience Hardy–Gill Resilience
Not reported 4.7/9
1.53
middle
14 item Resilience Scale Physical resilience Scale CD_RISC
89.81/98
9.34
top
12.69/15
2.35
top
75.7/100
13.0
top
Resilience Appraisal Scale
52.12/60
7.25
top
24
Table 4. Factors with correlations with resilience Factor
correlation
Self-rated health
0.31-0.37 1.65 2.20)
source p<0.001
(1.24- p<0.05
Wagnild 2003 Hardy et al. 2004
0.41
p<0.01
Pierini and Stuifbergergen 2010
0.14-0.25
p not reported
Leppert et al. 2005
0.116
p<0.001
Lamond et al. 2008
0.24
p=0.02
Wells 2009
Oral health
PR = 1.18
CI 1.06-1.32
Martins et al. 2011
Mental health
0.31
p<0.001
Hardy et al. 2004
0.37
p<0.01
Nygren et al. 2005
0.26
p<0.001
Mehta et al.2008
0.58
p=0.00
Wells 2009
0.37-0.59
p<0.001
Wagnild 2003
0.281-0.586
p<0.01
Hu et al. 2009
0.41
p not reported
Leppert et al. 2005
0.494
p<0.001
Lamond et al. 2008
p<0.001
Hardy et al. 2004
p<0.05
Ong et al. 2006
Physical health
Life satisfaction
Well being
Perceived stressfulness of 0.48 event 0.38 (1a) 0.31 (1b) 0.38 (2) Sense of Coherence Scale
0.35
p<0.01
Nygren et al. 2005
Cognitive function
0.403
p<0.001
Lamond et al. 2008
25
0.281,
p=0.009
Fortes et al. 2009
Problem solving
β = 2.12
p<0.0001
Gooding et al. 2012
Purpose in Life Test
0.53
p<0.01
Nygren et al. 2005
Self -Transcendence Scale
0.49
p<0.01
Nygren et al. 2005
Positive emotions
0.41(1a)
p<0.05
Ong et al. 2006
0.37 (1b)
p<0.05
Ong et al. 2006
0.41 (2)
p<0.01
Ong et al. 2006
β =3.07
p<0.0001
Gooding et al. 2012
Optimism
0.438
p<0.001
Lamond et al. 2008
Spiritual growth
0.51
p<0.01
Pierini and Stuifbergergen 2010
Social support
0.142
p<0.001
Lamond et al. 2008
1.4(1.1-1.8)
not reported
Netuveli et al. 2008
0.20
p=0.04
Wells 2009
0.44
p<0.01
Pierini and Stuifbergergen 2010
β =1.27
p<0.05
Gooding et al. 2012
26
Figure 1 Flow chart of search results
Records identified through database searching (n = 218)
Additional records identified through pearling (n = 9)
Records after duplicates removed (n = 142)
Records excluded via title and abstract (n = 59) Records screened (n = 142 )
Not older people (n=19) Not resilience of individuals e.g. couples/marriage resilience (n=6) Vitamin D (n=1) Thesis/book (n=33)
Full-text articles assessed for eligibility (n =83)
Full-text articles excluded, with(n = 41) reasons
Studies included in synthesis(n =42)
Not empirical (n=6)
Not older people (n=5) Not explicitly about resilience (n=19)
Insufficient data for abstraction (n=11)
