Developing the Resilience Framework for Nursing and Healthcare

Resilience as a state

Resilience is most frequently described as a construct that includes a cluster of concepts. Resilience as a state incorporates concepts of maintenance (Stewart & Yuen, 2011), equilibrium (Bonanno, 2004; Wagnild & Young, 1990), hardiness (Wilks et al., 2011), psychosocial well-being (Bekhet & Avery, 2017; Fletcher & Sarkar, 2013; Gillespie et al., 2007; ; Shaw et al., 2009), and equanimity (Wagnild, 2003). Resilience is seen as a positive and sustaining outcome, often allowing an individual to flourish despite their present life circumstances (Molina et al., 2014). Mancini and Bonanno (2009) further considered resilience as a particular trajectory or mechanism of positive adaptation that changes over time and protects against psychological distress.

Resilience as a process

Resilience as a process reiterates “the action or an act of rebounding or springing back; rebound, recoil” (“Resilience,” OED, 2020, Entry 163619). Securing internal and external resources to flexibly manage illness articulates this process of resilience (Haase et al., 2017). Competency (Greene et al., 2004; Haase et al., 2017; Masten, 1994), adaptation (Kimura et al., 2019), and positive adjustment during adversity outline actions taken during a changed life trajectory (Alizadeh et al., 2018; Black & Dorstyn, 2015).

Most authors agree, however, that resilience commences with adversity (Ungar, 2003). Some recognize that this adversity is an event (e g., acquiring a spinal cord injury, cancer diagnosis); others might consider it the result of a long-term stressor (e.g., mental-health issues or an abusive home environment). Longstanding risk factors include poverty (Garmezy, 1993), being shamed or bullied (Brown, 2006), homelessness (Rew & Horner, 2003), and post-traumatic stress disorder (Zarzaur et al., 2017), all of which are considered adversarial to the individual.

The conseptualization of resilience as strength-based

A strength-based conceptual consideration is inherent in reviewing resilience as both a state and a process. A strength-based perspective is a construct used by social work and psychology to identify internal, positive strengths that the client brings to a situation. These can include past experiences, talents, and skills and are vital components of the person’s ability to “bounce back” after a life-altering diagnosis. An illness, or a new diagnosis of illness in their loved one, poses a unique and uncharted challenge. A strength-based consideration weaves exclusive internal elements and physical deficits that the patient is experiencing, and this, in turn, sustains resilience (Greene et al., 2004). Bonanno et al. (2006) note the many unforged “pathways to resilience” (p. 20) that exemplify the strengths an individual possesses, and they identify practices that can accentuate this internal attribute.

Theoretical perspectives

The following authors have developed major research programs exploring resilience.

Bonanno (2004)

Bonanno’s contribution to the field is the recognition that resilience is the most common, natural reaction to loss or trauma, including post-traumatic stress disorder (Bonanno, 2004). He introduced a rigorous method of research applicable to both bereavement and trauma. Bonanno and his colleagues focused on what goes wrong with people who become chronically symptomatic with poor functioning after adversity while simultaneously seeking to learn which natural mechanisms allow people to cope with adversity (Southwick et al., 2014).

Rutter (2012)

Rutter viewed resilience through the lens of child development. As a child psychologist, his research examined the varied responses to stress experienced by children and the supporting role that the environment, genetics, family, and peers play to influence risk factors (Rutter, 1979, 2012; Rutter & Rutter, 1993). Resilience comprises internal and external supports that act as protective factors (Rutter, 2012). These polarize the effects of stress, accentuating positive responses, and mitigating negative ones as they relate to emotional and cognitive development in children (Rutter & Rutter, 1993).

Greene (2002)

From the field of social work, Greene offered an alternative perspective on resilience, namely, that it is a biopsychosocial and spiritual phenomenon involving a transactional dynamic process of person-environment exchanges. Greene proposed that resilience encompasses an adaptational process of goodness-of-fit and occurs across the life course with individuals, families, and communities experiencing unique paths of development.

Resilience in nursing and health

Stewart and Yuen (2011) explored resilience research and conducted a systematic review comparing psychological factors and coping strategies in adults with children with chronic illness. They concluded that resilience matched with symptoms associated with physical illness, demonstrating that pain is more prominent with a debilitating physical disease like arthritis (Stewart & Yuen, 2011). In their systematic review there was little mention of the role healthcare providers have in maintaining or regaining mental health in their patients who are experiencing adversity.

Many concepts shown to enhance resilience during the management of chronic illness or during the course of a disability have been incorporated independently into nursing theory. While resilience in itself is extremely relevant to nursing care and therapeutic outcomes, nursing has not embraced resilience per se. Some nurse researchers have explored resilience as a concept (Ahern et al., 2006; Olsson et al., 2003), but treating resilience as a concept does not enable the development of a caregiving and supportive framework that might enhance nursing.

One exception is the extensive research program by Haase and her colleagues, which explored resilience as a concept, developed an instrument to measure resilience (Haase et al., 1999), presented a mid-range theory (Haase & Peterson, 2015), and conducted subsequent quantitative testing (Haase et al., 2017). Haase’s research program targeted adolescents with cancer and explored concepts that enabled resilience, such as spirituality (Taylor et al., 2015), family communication and cohesion (Bell et al., 2007), social support (Bell et al., 2007), and information needs (Decker et al., 2004). The Adolescent Resilience Model (Haase, 2004) was developed to guide interventions for adolescents with cancer. From Haase’s work, a consensus statement (Nelson et al., 2004) and interventions were developed and applied using The Adolescent Resilience Model to improve care to adolescents with cancer and their families (Haase, 2004). Haase’s contribution to our understanding of resilience is extraordinary, but it is targeted exclusively to adolescent oncology. A less specific framework for the conceptualization and application of resilience for illness and utilization in nursing has yet to be proposed.

Resilience as a response to surgical transplants

Class of illness: Major solid-organ transplants.

Index case: Patients who experience lung transplants.

Those who require lung transplants have experiences similar to those who undergo any major solid-organ transplant. They usually have a period of illness and physical decline prior to their transplant. The transplant itself is a major surgical event with a long period of recovery, continuous medication and medical surveillance; and it involves uncertainty of success. The waiting period prior to transplant includes significant loss, changes in role identity, attention to the medical system, and introspection (Brown et al., 2006). Continuous medical monitoring for signs of rejection or infection continue postoperatively.

We identified the index case of lung transplant as it includes coping concepts applicable to all solid-organ transplant survivors. Lung transplant recipients, for example, originate from several different processes varying from chronic obstructive pulmonary disease (COPD) to cystic fibrosis. Although improvements to survival increase each year, the peak quality of life post-transplant is noted around 12 months post-surgery (Rosenberger et al., 2012). Concepts enabling resilience concepts post-operatively protect against psychosocial problems of persistent fears of transplant rejection and despair associated with a return of hypoxia (Cohen, 2014; Rosenberger et al., 2012). Resilience enables toleration of activity restrictions, and challenges patients to adopt new stress-reduction techniques and to comply with complex treatment regimens (Barbour et al., 2006; Singer & Singer, 2013).

The patient who experiences living with a lung transplant has commonalties with other solid-organ transplant survivors, expanding this class of illness. Major transplant survivors use strategies represented by protective coping concepts of hopefulness (Molina et al., 2014), mastery and religiosity (Myaskovsky et al., 2006), optimism (Molina et al., 2014), regimental control (Rosenberger et al., 2012), and a pessimism-realism orientation (Brügger et al., 2014). Compensatory coping concepts in transplant survivors include those for the management of fear (Husain et al, 1999), inadequacy (Singer & Singer, 2013), uncertainty (Naef & Bournes, 2009), post-traumatic stress disorder (Cohen, 2014), stigma/guilt (Brügger et al., 2014; Rosenberger et al., 2012), and vulnerability (Husain et al, 1999).

Resilience as a response to living with cancer

Class of illness: Living with uncertain prognosis.

Index case: Breast cancer.

Breast cancer was initially identified as the index case, yet has many commonalities with the class of all cancers, albeit differing in prognosis, trajectory and outcome. The diagnosis of cancer is usually stressful, life-threatening (Morse et al., 2014) and followed by two broad trajectories. Both of these trajectories usually commence with treatment of the cancer, which might include surgery, chemotherapy, and radiation. The first trajectory is when the cancer is malignant and advanced and these treatments are of limited effectiveness, and the patient might decline, entering a time of increasing debility, and potentially palliative care and death. In the event of treatment, the second trajectory is predominantly one of uncertainty and hope over time. With respect to surgery and prolonged therapies, monitoring for possible recurrence and pacing through milestones—most commonly 5 years “cancer-free”—become significant markers. Should the monitoring reveal recurrence of the cancer, or should the cancer metastasize to other sites in the body, the trajectory might move to increasing debility, palliative care and death.

Regardless of the course of the disease, the initial diagnosis causes emotional distress (Breen et al., 2009; Harrison & Maguir, 1994; Morse, 2011; Weisman, 1979). Protective concepts enter at this stage. Self-compassion and social support play an important role during the diagnosis and treatment for the attainment of resilience. The ability of an individual to adjust through both physical and emotional adversity requires the extensive use of strategies represented by compensatory coping concepts, which contribute to building resilience, including hope, motivation (de Moor et al., 2006), optimism (Gardenhire et al., 2019), a sense of coherence (Boscaglia & Clarke, 2007), preexisting and perceived social support, spirituality (Herth, 1992; Lo et al., 2010; Snyder et al., 1991), self-compassion, and a sense of belonging. Challenge-related concepts include knowledge, quality of life, and positive adjustment (Aspinwall & MacNamara, 2005). If the cancer patients are able to cope and develop resilience, they might be less dependent on psychosocial support for the management of their stressful conditions relative to those with low resilience (Brix et al., 2008).

Resilience as response to living with mental illness

Class of illness: Self-awareness of mental illness.

Index case: Anxiety.

Of those mental illnesses of which the persons themselves are aware, a defining feature is the psychological distress that those affected will suffer as a direct result of these illnesses. The specific identification of generalized anxiety disorder (GAD), major depressive disorder (MDD), and post-traumatic stress discorder (PTSD) was derived from the broader category of psychiatric illnesses with self-awareness. Becoming resilient has been noted to act potentially as a buffer that helps to reduce the prevalence of these mental-health conditions (Sheerin et al., 2017; Thompson et al., 2018a).

These diseases are often highly visible to the affected individual and to others, and have the potential to cause devastation to physical health, social, and family relationships, employment, and other critical aspects of life. Shame and stigma can inhibit the individual’s ability to seek care. Common problems encountered in this group are anxiety, behavior disengagement, denial, depression, fatigue, fear, guilt, shame, isolation, numbing, self-blame, stigma, stress, substance use, suicidality, venting, and vulnerability (Mong et al., 2012; Neria et al., 2010; Thompson et al., 2018a; Villaggi et al, 2015). This emotional upheaval serves as a powerful barrier or means to self-protect (or protect), by using self-managing concepts that lead to successful coping (Villaggi et al., 2015). Concepts that have been identified as frequently supporting resilience by compensation include acceptance, hope, humor, self-efficacy, social support, spiritual belief, and physical exercise. Planning, purpose, positive reframing, and mindfulness, (Min et al., 2013; Mong et al., 2012; Thompson et al., 2018a) can be considered challenge-related concepts. One who copes well following adversity or stressors is generally termed resilient in the mental-health community (Sheerin et al., 2017). Yet this prompts the questions, why do some individuals seem to possess more resilience, and how can those deemed to have poor resilience and coping ability develop these skills to aid in recovery and prevent recurrence? Harnessing resilience-focused concepts enable individuals with mental-health disorders to adapt successfully to equanimity and buffer against future hardship.

Resilience as a response to living with chronic pain

Class of illness: Ongoing chronic painful conditions.

Index case: Arthritis.

Arthritis is a chronic painful condition which shares common characteristics with osteoarthritis and rheumatoid arthritis, as well as back pain and fibromyalgia. These ongoing chronic painful conditions are a class of conditions that create unique challenges to those affected. While chronic pain conditions do not present a direct threat to life, they can affect ability, mental outlook, job performance, and mobility for the remainder of the afflicted person’s life (King et al., 2003; Tokish et al., 2017). Osteoarthritis and rheumatoid arthritis present clinically with joint swelling, pain, and immobility (Beeckman et al., 2019; Mangelli et al., 2002). Specific concerns about these chronic painful conditions relating to mobility include preclusion from event attendance, physical vulnerability, and isolation (Beeckman et al., 2019; Liu et al., 2017; Shaw et al., 2019). People living with arthritis also bear worries about future immobility limitations that might require the use of canes, walkers and wheelchairs.

Resilience concepts help improve the pain and procedural outcomes for chronic painful conditions (Hemington et al., 2018; Thompson et al., 2018b; Tokish et al., 2017), and improve adaptability to life changes with arthritis (Hemington et al., 2018). These changes require active “work” throughout the process of seeking resilience. The following concepts have been linked to working toward resilience: acceptance (Shaw et al., 2019), autonomy (Becker & Newson, 2005; Cartwright et al., 2015; Hassani et al., 2017; Mangelli et al., 2002), hope (Xu et al., 2017), optimism (Shaw et al., 2019; Thompson et al., 2018b; Xu et al., 2017), patience (Hassani et al., 2017), perseverance (Shaw et al., 2019), sense of purpose (Hassani et al., 2017; King et al., 2003; Liu et al., 2017; Mangelli et al., 2002; Rojas et al., 2018), self-efficacy (Xu et al., 2017), self-growth (Cartwright et al., 2015; Mangelli et al., 2002), social support (Cartwright et al., 2015; Hassani et al., 2017; King et al., 2003; Mangelli et al., 2002; Musich et al., 2019; Robinson et al., 2019; Shaw et al., 2019; Xu et al., 2017), and well-being (Beeckman et al., 2019; Hassani et al., 2017; Mangelli et al., 2002). Chronic pain researchers also identified these coping concepts as contributors to a resilience outcome (Cartwright et al., 2015; Hassani et al., 2017; Hemington et al., 2018; Rojas et al., 2018; Shaw et al., 2019).

Resilience as a response to incurable episodic illness

Class of illness: Episodic illnesses.

Index case: Asthma.

A class of illnesses that occur as episodes, or repeated “attacks,” such as asthma, provides the person and their family or support system with the opportunity to recognize the onset of the occurrence of the disease and to learn emergency responses in order to intervene, control and even prevent more serious and debilitating consequences of the disease—that is, to learn to become resilient over time. Episodic illness in this category includes such conditions as asthma, migraine, and sickle-cell disease.

For example, asthma is a disease of airways currently without a cure and can only be managed (Asthma Society of Canada, 2020). The condition will not only compromise physical well-being, but will also associate with a range of psychological consequences. Common symptoms like shortness of breath, regular coughing, wheezing, trouble sleeping, and limited physical activities inhibit the patient from leading a “normal” life. In addition to the symptoms, the patient might feel abused, depressed, afraid, lonely, mentally fatigued, shamed, stressed, vulnerable, and inadequate (Barton et al., 2003; Coogan et al., 2013; Lehrer et al., 2002; Metting et al., 2016). In the US, over 24 million people are suffering and coping with this incurable illness (CDC, 2018). Management of symptoms might be the only way for this population to lead a normal life.

For incurable episodic illnesses (i.e., sickle-cell disease, asthma, migraine), therefore, the focus is on control, management, and readjustment after every episode of the syndrome (Bromberg et al., 2012; Vinson, 2002; Williams-Gray & Senreich, 2015). Additionally, over time, such patients might improve their management skills by achieving equanimity. Therefore, concepts of coping are the key to boosting resilience in episodic illnesses. Frequently used protective coping-concept strategies are family cohesion (Fuggle et al., 1996; Koinis Mitchell et al., 2004), hope (Simon et al., 2009; Vinson, 2002; Ziadni et al., 2011), humor (Williams-Gray & Senreich, 2015), knowledge (Fuggle et al., 1996), mutual aid (Ladd et al., 2014), social support (Chen et al., 2011; Montoya et al., 2004; Vinson, 2002), and spiritual belief (Williams-Gray & Senreich, 2015). Frequently used compensatory-concept strategies are empowerment (Vinson, 2002; Williams-Gray & Senreich, 2015), management (Bromberg et al., 2012; Fuggle et al., 1996), and optimism (Chen et al., 2011; Vinson, 2002). Finally, frequently used challenge-concept strategies are empowerment (Vinson, 2002; Williams-Gray & Senreich, 2015), normalization (Protudjer et al., 2009), and self-esteem (Chen et al., 2011; Vinson, 2002). These coping-concept strategies guide patients with episodic illnesses to recalibrate and readjust, thus improving their ability to be resilient.

Resilience as a response to trauma

Class of illness: Unexpected and unanticipated accidents or trauma.

Index case: Spinal-cord injury.

An adverse traumatic event that results in injury is the index case in this class. These injuries can have catastrophic effects on the injured and those close to them. Examples in this category include injuries from major unexpected or unanticipated events, resulting in a major traumatic injury, such as war injuries or motor-vehicle accidents which require extensive intervention.

Consider, for instance, our index case—a major accident resulting in a spinal-cord injury that upends a person’s life, creating a new state of dependence during performance of activities of daily living and causing chronic pain, anxiety, social stressors, and prolonged rehabilitation (Craig et al., 2014, Guest et al., 2015). Distress, depression and altered functioning are frequent outcomes; and the inability to accept the current status makes it difficult to progress toward rehabilitation and overall improved wellness (Bonanno et al., 2012).

Over time, those who consider injury a challenge to be overcome and who use coping skills—both inherent and learned—have a higher likelihood of recovery (Bonanno et al., 2012; Kornhaber et al., 2018; Machida et al., 2013). It has been shown that exhibiting resilience is predictive of psychological, physiological, and sociological wellness among those with a sudden injury or accident such as a spinal-cord injury (McDonald et al., 2019). Some of these learned behaviors include mood management, not just physical recovery (Kilic et al., 2013). One of the most pertinent compensatory coping-concept strategies for those with a sudden illness or injury is optimism (Edward, 2013; McDonald et al., 2019; Stewart & Yuen, 2011; Wagnild, 2003).

Strong social support encompasses protective, compensatory, and challenge-related coping-concept strategies (Ahern et al., 2006; Bhattarai et al., 2018; Edward, 2013; Machida et al., 2013; Monden et al., 2014; Shin et al., 2012; Spratling & Weaver, 2012). The ability to adapt to injury and resultant changes (Ahern et al., 2006; Bhattarai et al., 2018; Edward, 2013; Hunter & Chandler, 1999; Jones et al., 2019; Kornhaber et al., 2018; Machida et al, 2013; McDonald et al., 2019; Monden et al., 2014; Spratling & Weaver, 2012), and the act of serving as a role model or inspiring others (Monden et al., 2014), are key challenge-related coping-concepts strategies. Salient protective coping-concept strategies include spirituality (Bhattarai et al., 2018; Jones et al., 2019; Monden et al., 2014); psychological strength (Monden et al., 2014; Tusaie & Dyer, 2004); and perspective (Garmezy, 1993; Monden et al., 2014). Once obtained, resilience enables the individual to thrive despite the injury (Shin et al., 2012).

Resilience as a response to dyadic dependency

Class of illlness: Caregiving for the frail and ill.

Index case: Caregiving for a person with Alzheimer’s disease.

Caregivers as a group have been selected and included as a class because these individuals, and those they care for, must be considered as a unit, and their dyadic responsibilities to the frail and ill, are important to health and resilience. Additionally, health implications and resulting sequelae (including stress responses) are directly related to caregiving responsibilities for the caregivers themselves.

Informal caregivers, representing nearly 30% of the adult American population, provide essential assistance with activities of daily living and medical care (Hudson et al., 2020). Caregivers help to facilitate resilience in those they care for by buffering the adversity and stress experienced by the ill person; in this way, such caregiving acts as a protective factor.

Studies, however, have documented physical and mental consequences of caregiver burden, including depression, anxiety, social isolation, loneliness, difficulty balancing professional and personal responsibilities, increased occurrence of chronic conditions (Aoun et al., 2018; Brodaty & Donkin, 2009; Deist & Greeff, 2017), difficulty accessing support resources, compassion fatigue (Ferrell et al., 2019), and suicidal ideation (dos Santos Treichel et al., 2018), underlining the importance of developing resilience in the context of caregivers themselves.

Alzheimer’s caregivers have been identified as our index case of caregivers, as they frequently experience both physical and mental psychosocial problems because of the nature and demands of their role. Persons with Alzheimer’s will experience declines in cognitive functions which ultimately impact their ability to carry out activities of daily living (ADLs), resulting in their dependence on formal or, more often, informal caregivers (Plassman et al., 2007). Coping-concept strategies that support resilience in caregiving for persons with Alzheimer’s encompass challenge-related coping-concept strategies such as the finding of meaning in their role as a caregiver. Protective and compensatory coping-concept strategies associated with caregiving for persons with Alzheimer’s include spirituality, optimism, resourcefulness, self-care, knowledge (about the disease), positive communication patterns, family connectedness, and social support (Aoun et al., 2018, Bekhet & Avery, 2017; Deist & Greeff, 2017).

Expanding this class of conditions to caregiving situations in which the person is dependent for most ADLs can also include persons with other types of dementia, parents of disabled children, caregivers of person with cancer, and caregivers of those with mental illness or severe mental deficits. Caregiver stressors might mirror the needs of those for whom they provide care. For example, caregivers of those who have physical deficits will likely provide more assistance with ADLs. Caregivers of persons with mental illness and/or deficits may or may not provide as much help with ADLs, but these caregivers might be at greater risk for experiencing problems with family dynamics. They can have more difficulty securing additional support and resources for such psychosocial issues (Ferrell et al., 2019). These examples illustrate how developing resilience in caregivers subsequently optimizes functioning, both in the dependent person and within the family unit.

These classes of illness discussed above and the psychosocial problems associated with them are summarized on Table 1. Note that these seven index cases and classes of illness are not exclusive—for instance we have not included palliative care and the patients who are dying, infectious diseases, cardiac diseases, and so forth, but those presented here provide a beginning, and a useful taxonomy that addresses the psychosocial aspects of care and associated coping concepts.

OPEN IN VIEWER

Table 1.

Common Psychosocial Problems and Coping Concepts for Index Cases and Classes of Illnesses.

I. Identifying the Index Cases ↓
Lung Transplant	Breast Cancer	Anxiety	Arthritis	Asthma	Spinal-Cord Injury	Alzheimer’s Caregiver
II. Identifying the Classes of Illnesses ↓
Major Solid-Organ Transplants	Living with Uncertain Prognosis	Self-Awareness of Mental Illness	Ongoing Chronic Painful Conditions	Episodic Illnesses	Unexpected and Unanticipated Accidents or Trauma	Dyadic caregiving for the Frail and Ill
III. Identifying Common Psychosocial Problems ↓
Anger Anxiety Depression Exhaustion Fear Hopelessness Inadequacy Role modification Stigma/guilt Uncertainty Vulnerability	Anxiety Depression Distress Exhaustion Fatigue Fear Mental adjustment Stress	Anxiety Depression Fatigue Fear Isolation Stress Vulnerability	Chronic pain Depression Isolation Social functioning Stress Vulnerability	Abuse Depression Fear Isolation Mental fatigue Shame Stress Vulnerability Sense of inadequacy	Anger Anxiety Comorbidities Chronic pain Dependency Fear Grief Hopelessness Isolation Vulnerability	Altered self-identity Anxiety Comorbidities Depression Isolation Vulnerability
IV. Identifying Commonly Used Coping Concepts ↓
Disability status Hopefulness Mastery Optimism Pessimism/realism Spirituality Regimental control Social support	Communication Emotional processing Hope Optimism Positive appraisal Social support Spirituality	Acceptance Hope Humor Mindfulness Planning Reframing Self-efficacy Social support Spirituality	Acceptance Autonomy Hope Optimism Patience Perseverance Purpose Self-efficacy Self-growth Social support Well-being	Empowerment Hope Humor Normalization Optimism Social support Spirituality Self-esteem	Acceptance Adaptation Experience Hope Inspiration Mentorship Optimism Perseverance Self-care Social support Spirituality	Acceptance Communication Knowledge Mastery Meaning finding Optimism Perspective Resourcefulness Self-care Self-efficacy Social support Spirituality
V. Concepts Sorted into Stages in the Illness Trajectory (Table 2) ↓
VI. Equanimity Identified as an Indicator of Resilience ↓
VII. Development of The Resilience Framework for Nursing and Healthcare

Protective factors

In this framework some coping concepts may be categorized as protective in nature, in that they assist in alleviating the initial distress. However, based on the evidence in this analyisis, we dispute the application of the term “protective factors” to all coping concepts, as the term fails to account for the work of resilience and mutes the role of compensatory and challenge-related concepts in contributing to the work of becoming resilient. All coping concepts are not “protective.”

The state of equanimity

Here, we have selected the emotional state of equanimity as the outcome of the process of becoming resilient. Bonanno (2004) is correct when he writes that “resilience is different from recovery” (p. 20). Equanimity enables the channeling of energy from distress to the focus on coping-concept strategies and therapeutic programs, thereby enabling the final stage of recovery, recalibration, and readjustment toward health. Equanimity is the realistic acceptance of the impact of the individual’s current health status and their prognosis (Emlet et al., 2011), and is an indicator that the individual has attained resilience. Acceptance in equanimity is different from acceptance in self-transcendence (Mayan et al., 2006). Equanimity is active. Self-transcendence is the passive peace that occurs with the acceptance of a terminal diagnosis.

The particularity of coping concepts

Some researchers have suggested that there is a set of concepts that occur in all illnesses for the attainment of resilience. For example, optimism, social support, spirituality, and hope are commonly used. In this study, we have found that some concepts are relevant to certain classes of illness, but that only social support was relevant to all illness classes. Our review of the literature and synthesis of coping concepts found that some coping concepts were evident within many of the classes of illness. It must be noted, however, that we were unable to identify a list of universal coping concepts related to obtaining resilience across all classes of illness. By examining Table 2 we can see that specific concept sets relate to particular classes of illness. This is extremely important; extensive work and investigation should be undertaken in order to understand the needs of each class of illness so as to help patients attain the state of resilience.

The state of resilience

Resilience is a patient-centered concept, and the processes of attaining resilience have been described from the perspective of the patient. Yet attaining resilience is an interactive process, involving caregivers and significant others, particularly in the protective set of coping concepts. For instance, social support plays a significant role (in its various types—which, incidentally, have yet to be delineated or described), particularly in caregivers and significant others (when considered in the context of compensatory and challenge-related concepts). It is astonishing that trust is not predominant in this literature [for instance, see Robinson’s (2016) analysis of trust in the caregiver relationship]. Given one’s disabilities, handicaps, and impairments, the state of resilience enables one to achieve relative optimal health.

Does resilience go away? It becomes a part of the individual’s experiential memory (Srivastava & Sinha, 2012). Individuals do not have to be working toward resilience when operating in a state of equanimity. This is a more efficient form of maintaining resilience, one in which the individual can focus on regaining the activities of daily living.

Recurring adveristy

When another adverse event occurs and the person again responds with distress, the person leaves equanimity and reenters the framework at the beginning of pre-resilience (as seen in Figure 2). Prior experience with adversity will make this action more efficient and enable the individual to reach resilience more quickly. Internal and external supports might be needed, however, to buffer the challenge of experiencing so many adverse events in such short succession that their experience could overwhelm pre-established coping mechanisms.

Another aspect to consider in this process would be the duration of time between adverse events and how this timeline might impact an individual’s ability to efficiently reenter the resilience framework. Should too much time pass, will these learned behaviors be forgotten? Will the resources available to the individual have changed radically during this time? And will that change alter, in turn, the individual’s approach and coping concepts employed to navigate through the resilience framework?

Limitations

Rather than collecting targeted “raw” data within a specific project to develop this framework, we constructed the components using qualitative literature. While this means that the framework has the limitation of not been tested “in the real world” or in the clinical setting, the logical application and support of exising literature is a strength.