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Resilience: A Historical Review

of the Construct

Kathleen Tusaie, PhD, APRN-BC Janyce Dyer, DNSc, CRNP, CS

Evolution of the construct of resilience from physiological and psychological research extends from the 1800s
to the present. This review supports 3 observations: (1) the importance of a dynamic, interactive perspective
for understanding resilience; (2) the complexity of the construct requires a holistic perspective; and (3) the
importance of exposure to diverse experiences and educational perspectives for professional health care students.
KEY WORDS: anxiety, holistic, resilience, stress Holist Nurs Pract 2004;18(1):38

esilience is a vital attribute for nurses in

their everyday work and particularly amidst the
current nursing shortage. It denotes a combination of
abilities and characteristics that interact dynamically
to allow an individual to bounce back, cope
successfully, and function above the norm in spite of
significant stress or adversity.1 Although researchers
agree on multiple domains to the concept of resilience,
it can be viewed as a qualitative categorical construct2
or as a continuum of adaptation or success
experiences.3 Its complexity necessitates an additional
holistic nursing perspective.
The domains of work or school performance,
behavior adjustment, psychosocial adjustment, and
physical health comprise overall resilience.1,2,4
Because of a weak correlation among the domains of
resilience, individuals may vary in resilience
characteristics. For example, an individual from an
abusive, impoverished childhood may demonstrate
education and work resiliency by obtaining a doctoral
degree and a high-paying job, but be unable to
maintain intimate relationships and demonstrate
impairment in the psychosocial domain. Therefore,
current evidence suggests that the idea of overall
resilience is of questionable utility.3,5 Definitions that
focus on aggregating various domains are likely to be
weakly correlated with outcomes. So domain

From the University of Akron College of Nursing, Akron, Ohio (Dr Tusaie);
and the Barry University School of Nursing, Miami Shores, Fla (Dr Dyer).
Corresponding author: Kathleen Tusaie, PhD, APRN-BC, University of
Akron College of Nursing, Mary Gladwin Hall, Akron, OH 44325 (e-mail:
ktusaie@uakron.edu).

specificity is more useful in research and practice

applications than is a global definition of resilience.6
The domains of resilience are developmentally
appropriate and change with different life stages. For
example, in addition to the absence of illness, children
who function above the norm scholastically and in
peer relationships in spite of risk exhibit resilience.711
In adolescence and young adulthood, resilience may
be measured by accomplishments higher than the
norm in career development, happiness, relationships,
and physical well-being in spite of the presence of risk
factors.12 Resilience is not static.
Resilience has been studied particularly in relation
to transitions of greatest stress. Developmental
transitions include school entry, detachment from
parents during adolescence, and childbearing.
Transitions also occur in unexpected or externally
controlled events such as disaster, family disruption,
or unemployment.1317 These and other forms of
stressful situations place individuals at risk for the
development of psychosocial or physical symptoms.
Individuals who do experience disruption from stress
but then use personal strengths to grow stronger and
function above the norm are considered resilient.
Although each individual possesses the potential
for resilience, an interplay between the individual and
the broader environment is responsible for the level of
resilience.1,7 Further, the interactions among risk and
protective factors at an intrapersonal and
environmental level are integral to the definition of
resilience. The presence of risk factors indicates that a
person has been identified as with a group that is more
likely than other groups to develop a specific
3

HOLISTIC NURSING PRACTICE JANUARY/FEBRUARY 2004

difficulty.18 Risk factors do not predict a particular

negative outcome with absolute certainty; they only
expose individuals to circumstances associated with a
higher incidence of that outcome. Risk factors stem
from multiple life stressors, a single traumatic event,
or cumulative stress from a number of individual and
environmental factors.1,3,4,16 The risk may be viewed
from an epidemiological perspective that would
include an entire group, such as children in poverty or
on an individual basis such as an experience of trauma
or an adverse event.9 The balance between risk and
protective factors is a dynamic process.
Protective factors are defined as operating to protect
those at risk from the effects of the risk factors.
Similar to risk factors, protective factors may be
individual or environmental and they contribute to
positive outcomes regardless of the risk status.18 The
manner in which risk and protective factors interact in
the person demonstrating resilience is not clear.
Understanding the root of causation often requires a
focus on the presence or absence of specific unitary
factors, and the nature of the interactions within the
collectivity of risk and protective factors. When stress
or the number of risk factors is greater than the
number of protective factors, individuals who
exhibited resilience in the past may be overwhelmed
and develop symptoms in one of the domains of
physical, psychosocial, behavioral school, or work.4
The prevalence of resilience ranges from 15% to
50% depending upon the definition of resilience and
the population studied.8,9,14,19 These rates suggest that
resilience does not function uniformly and
automatically, but waxes and wanes in response to
contextual variables.
Experts agree that the potential for change or
plasticity exists across the life course.10,11,15,2022 This
plasticity, or ability to bounce back in spite of
adversity and function above the norm, provides
reason for optimism about intervention programs to
promote health and prevent illness. Therefore, the area
of resilience is of interest to researchers, clinicians,
and educators. Many forms of stress and adversity
exist in our workplaces and in our world, but those
who cope successfully and function above the norm in
spite of adversity have valuable knowledge to share.

HISTORICAL DEVELOPMENT
The roots of the construct of resilience are in 2 bodies
of literature: (1) the psychological aspects of coping

and (2) the physiological aspects of stress. Fields of

study related to psychology and physiology are
simultaneously pushed apart by academic politics and
drawn together by common elements of the human
experience.23 This review of the literature will include
some of the literature that led to the evolution of the
construct of resilience (see Fig 1).
From the psychological literature on stress and
coping, observations of individuals coping better than
expected and actually improving as a result of
adversity laid the groundwork for the construct of
resilience. Although the construct uses a holistic,
multilevel approach similar to
psychoneuroimmunology, resilience focuses upon
positive outcomes, not illness. Thus, both constructs
are related but have a different emphasis.
The early studies of resilience focused upon factors
or characteristics that assist individuals to thrive from
adversity. These findings can be divided into
intrapersonal and environmental factors. Intrapersonal
factors identified include cognitive factors and specific
competencies. Cognitive factors include
optimism,2427 intelligence,9,2830 creativity,31,32
humor,31,33 and a belief system that provides
existential meaning, a cohesive life narrative, and an
appreciation of the uniqueness of oneself.2,3437
Competencies that contribute to resilience include a
wide range of coping strategies,38,39 social skills,
educational abilities, and memory above the average
level.2,40,41 Physical attractiveness has also been
reported to add to the level of individual resilience.9,42
The intraindividual factors contributing to higher
levels of resilience may be considered protective
factors within the individual.
Environmental factors that influence resilience
include perceived social support or a sense of
connectedness and life events. Social support has been
described as an important factor in several domains of
resilience.2,8,9 A brief definition includes the objective
quantity of social resources as well as the process of
maintaining relationships. Social support is a
transaction between the person and the environment.
Therefore, it is not only the number or function of
social relationships but also the perception of the
support that encompasses the definition of social
support.43 Individuals with a negative outlook toward
the support being offered may repel it, thereby
receiving and perceiving less support.44 Therefore, an
individual is not a passive recipient of social support,
but the process of social support is reciprocal and
dynamic. For example, parental support has been

A Historical Review of Resilience

FIGURE 1. Evolution of the construct of resilience.

reported to be moderately to strongly correlated

(r = 0.060.08, P < .001) with adolescent resilience
in all domains.27,45 However, parental overprotection
resulting in lack of successful accomplishments and
self-regulation by the child has been significantly
correlated (r = 0.53, P < .001) to substance abuse,
antisocial behavior, and low psychosocial resilience.45
Therefore, protective factors change within context
and dosing or amount of the factor present.
Several studies have reported that number and
recency of bad life events directly influence resilience.
It was not life change in general, but specifically the
number of events perceived as bad by the individual
that influenced level of resilience. However, this
research on life events raised questions that validated
the importance of a transactional relationship among
factors because not all individuals who experience bad
life events have low resilience.
As the resiliency literature expanded, it became
clear that individual and environmental factors may be
necessary but not sufficient to understand the construct
of resilience. The dynamic processes among the

factors mediate between the person and the

environment and the person and the outcome.
Therefore, models of resilience began to emerge in the
literature.
A Resilience Process Model proposed by
Richardson46 is similar to other models developed by
Rutter,1,8 Wolin and Wolin,31 and Masten.2 This
conceptual model posits the presence of
biopsychospiritual homeostasis within the individual,
which is influenced by adversity, life events, and
resilient factors. Following disruption of homeostasis,
there is a conscious or unconscious reintegration
resulting in 1 of 4 outcomes: (1) resilient reintegration
resulting in growth, self-understanding, and increased
resilience; (2) reintegration back to homeostasis;
(3) reintegration with loss; or (4) dysfunctional
reintegration.
Other researchers focused upon a more narrow
model of resilience. Mandelco and Rerry11 have
proposed resilience models specifically for children
and an adolescent model was developed by
Tusaie-Mumford.27 Another direction in model

HOLISTIC NURSING PRACTICE JANUARY/FEBRUARY 2004

development resulted in an expansion to describe

resilience in larger systems such as families47 and
communities.48 All models were consistent in
identifying resilience as a dynamic process involving a
personal negotiation through life and fluctuating
across time, developmental stage, and context.
The measurement of resilience has lacked empirical
instruments because of the diversity of definitions as
well as the trend to use qualitative studies for this
complex phenomena. However, as research grows,
there are more consistent themes in identifying
intraindividual factors that strongly correlate with
resilient outcomes in all domains. Early work
measured the absence of expected symptoms in
various populations. However, only the absence of
expected symptoms did not measure the essence of
resilience. So, in addition to the absence of symptoms,
specific attributes of resilience were measured.
Therefore, self-report instruments to quantify resilient
factors within the individual have been developed. The
Ego Resilience Scale (ER89) was developed by Jack
Block49 to identify the pure ego resilience qualities of
the personality. It was developed with community
samples of adults and used recently to evaluate
resilience in individuals residing in war zones.14
Several other scales have been developed using the
research literature as a framework with a community
sample.21,50 Biscoe and Harris (unpublished data,
1994) have developed resiliency scales for children,
adolescents, and adults, with samples from residents
of a substance abuse treatment center and the clinical
staff. These scales are based upon the framework from
Wolin and Wolin.31 None of these scales has been
widely used and lack generalizability due to
development with specific populations.
Another scale, Connor-Davidson Resilience Scale
(CD-RISC), has used the research literature to guide
development but has a wider adult sample consisting
of a community group, primary care outpatients,
psychiatric outpatients, subjects in a study of
generalized anxiety disorder, and subjects in clinical
trials for posttraumatic stress disorder.51 This scale
may assist in the process of identifying levels of
resilience in a wide range of populations as well as
quantifying changes in resilience during therapy. The
clearest descriptions and measurements of resilience
today consist of a quantitative scale correlated with
outcome measures specific to the population and
domain of resilience being studied combined with a
qualitative piece to address the individualized
dynamics of resilience.

Although the specific relationships among the

intraindividual and environmental factors remain only
partially understood, the need to maximize resilience
in an effort to decrease the rising rates of mental illness
has driven the development of resiliency training
programs. Some programs focused upon maximizing a
specific factor such as social support,52,53 while others
took a more traditional psychotherapeutic approach.51
Richardson54,55 developed a seminar format for
training adults in a corporate setting as well as high
school students. Although these programs demonstrate
initial improvement following the intervention, there
are no longitudinal studies to date that test resilience
promotion along with risk reduction in real-world
settings.

FUTURE DIRECTIONS AND LESSONS

OF HISTORY FOR RESILIENCE
What lessons have been learned from this historical
literature review and what are the likely directions of
future advances? We will make 3 observations: (1) the
importance of a dynamic, interactive perspective for
understanding resilience; (2) the complexity of the
construct requires a holistic perspective; and (3) the
importance of exposure to diverse experiences and
educational perspectives for professional health care
students.

A dynamic, interactive perspective

Reactions to stress can no longer be seen as isolated
events eliciting a response, but rather the outcome of
what has gone on before. There is a dynamic
interaction of patterns of coping responses, personality
characteristics, social support, and genetically
determined biological reactivity with an individuals
appraisal of a stimulus to effect neuroendocrine and
immune responses that influence resilience and health.
The historical literature on resilience has added to our
understanding of the human response to stress, but
much remains to be learned. Although the themes in
characteristics of resilient individuals have been
explored, there is a need to explore the dynamic
interactions of these characteristics. For example, if a
child is at risk because of parental loss, will a
substitute parent eliminate or minimize the risk factor?
Recent statistical advances such as Structural Equation
Modeling software allow this concurrent analysis to
provide more understanding of the dynamic nature of

A Historical Review of Resilience

resilience. Although it is important to analyze

individual characteristics in more detail, the history
indicates that the dynamic interaction is also vital to
resilience. This finding can be extended to the health
educator and provider who are cautioned not to take a
narrow perspective when working with clients.

Holistic perspective
A historical perspective encourages the recognition of
the importance of context. The expression of
resilience will be affected by the context, not only the
immediate context, but the larger contexts of age
cohort, family history, social class, nation/culture,
history, and gender.20 For example, social power or a
kind of force field affects the formation and
expression of resilience. For example, in 1944, a
20-year-old white American male storming the beach
in Normandy and a middle-aged Japanese woman in
an internment camp for US citizens of Japanese
ancestry would certainly express resilience in a
different manner. When considering the larger social
context of an individual, the appreciation of the
concept of resilience becomes more clear. To have this
perspective, it is important to use a holistic framework.

Diverse training
The third and final lesson is to consider the training of
many of the great figures in history. Sigmund Freud
started as a neurologist and Florence Nightengale
addressed issues ranging from sanitation to physical
health to interpersonal relationships. The area of
health promotion and illness prevention has greatly
benefited by the experiences and perspectives from a
diverse range of interests and education. As our
society continues to become more complex, health
practitioners in the 21st century will require diverse
training and experiences. The importance of
interdisciplinary teams and interdisciplinary training
as part of professional education can only add to the
understanding and application of the construct of
resilience.

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21. Wagnild G, Young H. Development and psychometric evaluation of the
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31. Wolin SJ, Wolin S. Bound and Determined: Growing Up Resilient in a

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39. Barbarin OA, Richter L, deWet T. Exposure to violence, coping resources, and psychological adjustment. Am J Orthopsychiatry.
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44. Varni J, Setogichi Y, Rappaport L, Talbot D. Psychological adjustment

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45. Neher L, Short J. Risk and protective factors for childrens substance
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47. Patterson J. Understanding family resilience. J Clin Psychol. March
2002;58:233246.
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49. Block J, Kremen A. IQ and ego resiliency: conceptual and empirical
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50. Bartone P, Ursano R, Wright K, Ingraham L. The impact of military
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51. Connor K, Davidson J. Development of a new resilience scale:
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53. Shapiro E. Chronic illness as a family process: a social-developmental
approach to promoting resilience. J Clin Psychol. 2002;17(11):832
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54. Richardson GE. High School Resilient Youth Curriculum Guide. Salt
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CE Test
Resilience: A Historical Review of the Construct
Instructions:

Read the article on page 3.

Take the test, recording your answers in the test an

swers section (Section B) of the CE enrollment form.

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CE TEST QUESTIONS
General Purpose: To provide registered professional
nurses with information on the construct of resilience.
Learning Objectives: After reading the article and
taking this test, you should be able to:
1. Define the construct of resilience and related factors.
2. Outline research findings on the physiological and psychological components of resilience.
3. Describe the importance of a holistic perspective and
diverse training relating to resilience.
1. Competencies that contribute to resilience include a wide range of coping
strategies, social skills, educational abilities, and
a. a belief system that provides existential meaning.
b. creativity.
c. memory above the average level.
d. optimism.
2. Which of the following has been reported to be moderately to strongly correlated with adolescent resilience in all
domains?
a. cognitive factors
c. intelligence
b. humor
d. parental support
3. The prevalence of resilience ranges from
15% to 50%, which suggest that
a. individuals with a negative outlook toward the support being offered, may repel it, thereby receiving
and perceiving less support.
b. many forms of stress and adversity cannot be prevented in our workplaces and in our world.
c. resilience does not function uniformly and automatically, but waxes and wanes in response to contextual variables.
d. the balance between risk and protective factors is a
dynamic process.
4. A neuroendocrine model of resilience
specifically for women was presented by
a. Biscoe and Harris.
b. Caudell and Gallucci.
c. Mandelico and Perry.
d. Wolin and Wolin.
5. A self-reported instrument to quantify resilient factors within the individual developed by Jack Block is the
a. Conner-Davidson Resilience Scale (CD-RISC).
b. Ego Resilience Scale (ER89).
c. Structural Equation Modeling.
d. Resilience Process Model.
6. Which is defined as a transaction between the person and the environment?

7.

8.

9.

10.

11.

12.

13.

a. bad life events

b. health promotion
c. risk factors
d. social support
According to the Resilience Process
Model, biopsychospiritual homeostasis
within the individual is influenced by adversity, resilient factors, and
a. developmental stage.
b. generalized anxiety.
c. life events.
d. social support.
Social power or a kind of force field
a. affects the formation and expression of resilience.
b. benefits a diverse range of populations.
c. places individuals at risk of developing psychosocial
or physical symptoms.
d. stems from multiple life stressors, a single traumatic
event, or cumulative stress.
The presence of risk factors indicates
a. the absence of expected symptoms in various
populations.
b. a person is in a group that is more likely than other
groups to develop a specific difficulty.
c. theres been a personal negotiation through life and
fluctuating across time.
d. intraindividual factors that strongly correlate with resilient outcomes in all domains.
Operating to protect those at risk from the
effects of the risk factors defines
a. diverse training.
b. intraindividual factors.
c. patterns of coping.
d. protective factors.
Several studies have reported that resilience is directly influenced by the number and recency of
a. bad life events.
b. developed coping strategies.
c. life change in general.
d. acquired social skills.
The ability to bounce back in spite of adversity and function above the norm is
a. competencies.
c. plasticity.
b. interplay.
d. reintegration.
Which of the following is software that allows concurrent analysis to provide more
understanding of the dynamic nature of
resilience?
a. Conner-Davidson Resilience Scale (CD-RISC)
b. Ego Resilience Scale (ER89)

14.

15.

16.

17.

18.

19.

20.

c. Structural Equation Modeling

d. Resilience Process Model
Who addressed issues ranging from sanitation to physical health to interpersonal
relationships?
a. Nightingale
c. Freud
b. Block
d. Vinson
What type of framework does not derive from the sum of individual parts, but
rather from their dynamic, complex interaction?
a. biological
c. holistic
b. historical
d. social
What has driven the development of resiliency training programs?
a. effort to decrease the rising rates of mental illness
b. internment camps for US citizens of Japanese ancestry
c. continued complexity of our society
d. parental loss and substitute parents
Parental overprotection resulting in lack
of successful accomplishments and selfregulation by the child has been significantly correlated to substance abuse,
antisocial behavior, and
a. dysfunctional reintegration.
b. higher levels of resilience.
c. low psychosocial resilience.
d. unemployment.
The roots of the construct of resilience
are in the psychological aspects of coping and the physiological aspects of
a. plasticity.
b. psychoneuroimmunology.
c. stress.
d. transitions.
During the evolution of the construct of
resilience, what physiological development occurred in the 1920s?
a. brain plasticity
b. emotional stress and morbidity
c. psychoneuroimmunology
d. quantum physics
The psychological idea of coping as
a conscious process was introduced
into the evolution of the construct of resilience during the
a. 1920s
c. 1960s
b. 1950s
d. 1990s

CE Enrollment Form
Holistic Nursing Practice, January/February 2004:
Resilience: A Historical Review of the Construct

LPN RN CNS NP CRNA CNM

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