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Resilience - Synthesis

Introduction

Resilience in older adults can be defined as the ability to ‘bounce back’ and recover physical and/or psychological health in the face of adversity. [1,2] Resilience is thought to be a dynamic process within individuals, changing over time in response to life experiences. [1-6] Being resilient or building resilience is influenced by a multitude of interrelated personal, social and cultural factors, and the availability and use of support services. [1-7]

Considering older people approaching or at the end of their life, resilience is important for the person, their family and carers as well as those providing care. [1-3,5-8]

Quality Statement

Despite an extensive search, the only systematic reviews addressing resilience in older adults in a palliative care context focussed on family carers of people with dementia. [5,7,8] Of the literature exploring resilience in older adults outside of a palliative care context, two systematic reviews [1,2] and a literature review in development of a concept analysis, [4] were included. Two systematic reviews focussing on nurses and healthcare professionals working in general palliative care were also included. [3,6]

Overall the quality of the evidence is low to acceptable, with poor reporting on methodology and quality of the studies being reviewed. [1,4] Only one paper was of adequate quality based on the reported design [2] though the research question was of least relevance. In general, the published research is not specific to a palliative or an aged care context and suggests significant opportunity for future research.

Evidence Synthesis

There are many conceptualisations of resilience in the literature [1,2], but very few addressing older adults. [1,2] The concept of resilience was originally referred to as a personality trait, however, increasingly it has been recognised as a dynamic process [4] influenced by life experiences and challenges. [1,2]

Resilience is a positive response to adversity change, trauma, or misfortune. [3,6,7] Initial exposure to these challenges is the key to activating this dynamic process [1-6] and the level of resilience someone might demonstrate is determined by how successful the individual is at coping with adversity. In the case of ageing and palliative care, a number of stressors can impact resilience of both the person and their family, such as symptoms of illness and health decline, social isolation, loss of independence, psychological suffering, managing grief and ultimately preparing for, and coping with, bereavement. [2]

Van Kessel [1] studied resilience in older people. To measure resilience, they note the common use of a 25-item Resilience Scale based on five themes: equanimity, self-reliance, existential aloneness, perseverance and meaningfulness. While it is acknowledged that adversity can build resilience, the said adversities appear to be ongoing life experiences rather than specific events, e.g. being old, suffering poor health, the process of dying, or the experience of bereavement. The review also discusses a second key construct of ‘ability’, that is the ability to cope with adversity, which appears dependent on other elements such as personality, skills to adapt and look to the future, as well as environmental factors like resources, access to care and social support. [1] The authors propose that, in this context, managers of residential aged care facilities (RACFs) support programs that help residents maintain linkages with family and local communities and, using a framework of resilience, evaluate aspects of care and resource allocation (e.g. internet access, caregiving etc.). [1] Similar approaches to build resilience could also be considered in community aged care.

In the review by Hicks et al. [4] ‘resilient ageing’ is posed as a new concept different to other healthy or positive ageing concepts, in that it can be applied in the health promotion of all older people including those who may be frail or have a life-limiting illness. [4] Core attributes of resilient ageing are considered to be ‘coping’, ‘hardiness’ and ‘self-concept’, [4] further supporting the similar construct of ‘ability’ discussed in the 2013 review by van Kessel. [1]

Coping

The theme of coping as described by Hicks et al. [4] could also include terms such as adaptation and attitude change and is regarded as a process of cognitive and behavioural efforts to manage psychological stress. In the literature the theme of coping is often associated with ‘loss’, adjustment to new living arrangements (e.g. RACF) and changes in physical and mental health status. Specific coping strategies for situations that cannot be changed, such as in the case of palliative care, were more often emotion-focussed. [4] Common protective factors of coping include inner-strength, optimism, flexibility, global wellbeing, social support, community support, problem-solving skills and leading to heightened adaptation.

Hardiness

While similar to resilience, hardiness is described as a personality trait; such as in people that can manage high levels of stress without succumbing to illness possess hardiness. [4] In the literature, populations that had experienced some form of marginalization were more likely to demonstrate hardiness. Protective factors of hardiness include social support, prior life experience of hardship, maintenance of a positive attitude, and having a strong faith.

Self-concept

Self-concept is another personality trait, but in the literature has been said to be comprised of as many as ten different traits. Although no one definition for self-concept is offered in the review by Hicks et al., [4] it is said to be related to self-worth and the ability to adjust oneself to cope and preserve self-esteem. Self-concept is greatly protected by maintenance of positive identity, personal development, interpersonal control, social integration, and well-being.

Overall protective factors of resilient ageing appear to be life experience and social support, however these have the potential to change depending on the person and the context, which may lead to inconsistencies in coping, hardiness and self-concept. [4] In the review, 40% of the literature found quality of life to be the main outcome of resilient ageing and is consistent with the focus of palliative care.

Resilience and carers of people with dementia

Caring for a person with dementia can be challenging yet not all carers report similar difficulties or level of distress. [7,8]

Two models have been proposed to describe the interrelated factors relevant to resilience for carers or people with dementia. [5,7] Both models include social and cultural characteristics, and psychological dimensions of caring. [5,7] In addition the model proposed by Teahan et al. [7] incorporates context of caring,  and the model from Parkinson et al. [5] includes maintaining physical health status, safeguarding quality of life and ensuring timely availability of key external resources.

Psychosocial interventions have a role in helping build resilience in this context. [5,7] These interventions include cognitive behavioural therapy, psychotherapy, family therapy, counselling, anxiety/depression management, stress management, education or psychoeducation, health education, and social support among others. More information is available in the palliAGED topic Psychosocial Care.

Many people with dementia are cared for at home by their spouse. [7,8] A review by Cross et al. [8] outlines factors which contribute positively to the psychological resilience of carers of people with dementia:

  • an acceptance of the inevitable deterioration of the person with dementia and an understanding of what to expect in order to prepare for the future
  • an awareness of their own limitations and the need for respite care
  • choosing to focus on what they have control over 
  • an absence of additional stressors (e.g. their own physical health, finances)
  • continued involvement in meaningful activities and with their social network
  • having support and someone to talk to from friends and support networks
  • practical or emotional support met their needs or preference
  • a perceived control in accepting or accessing family support 
  • relatives and friends maintaining contact with the person with dementia.

These factors are also included in the models mentioned above. [5,7] 

Resilience and healthcare professionals

Resilience in health professionals supports them to manage workplace stress. [3,6] Powell et al. [3] differentiate coping and resilience in palliative care nurses. Nurses can cope with looking after terminally ill people and their family with the support of colleagues, family and personal traits. Resilience can only be built when nurses explicitly reflect on, process and articulate their thoughts and feelings. [3] According to Powell, this articulation of thoughts and feelings helps them to make sense of their experience in a way that prepares them for future experiences. The importance of nurses having space and time to reflect on their experiences is also noted. [3]

Building on that study, Zanatta et al. found that resilience in palliative care healthcare professionals seemed to reduce death anxiety, traumatic experiences, stress and burnout facilitate compassion satisfaction, and positive thinking (hope and improved perspective). [6] 

Implications for policy and practice

Health professionals often have significant interaction with older adults in times of adversity, specifically in a palliative care context, and are in a position to influence a person’s resilience. [1,3,6] Enhancing social support systems, feelings of self-worth and identity can assist in coping strategies for the individual and therefore enhance resilience. [4] There are implications for the development of policy to address the need for access to adequate health care, services and resources required to survive adversity associated with the diagnosis of a life-limiting illness. These resources can positively shape life experiences and coping with adversity. [4]

Individuals who have previously experienced adversity and have ‘bounced back’ are likely to demonstrate resilience in their approach to a life-limiting illness. However, in recognising the role of social support, access to adequate healthcare resources and support and maintenance of self-concept in promoting resilience, it may be useful for healthcare models to build on this framework to support people and their family in palliative care.

Evidence Gaps

In the published research there is very little specific to resilience in a palliative or an aged care context. Future research efforts could include:

  • Factors affecting resilience in older adults in residential aged care across the continuum of the palliative care journey
  • The role of social networks and community supports in enabling the resilience of older people living in the community at the end of their life.
  • The relationship of resilience to death literacy, death-coping and hope in palliative care
  • The influence of the physical environment on the capacity of older people to be resilient

Page created 08 July 2021

  • References

  1. van Kessel G. The ability of older people to overcome adversity: a review of the resilience concept. Geriatr Nurs. 2013 Mar-Apr;34(2):122-7.
  2. Wermelinger Avila MP, Lucchetti AL, Lucchetti G. Association between depression and resilience in older adults: a systematic review and meta-analysis. Int J Geriatr Psychiatry. 2017 Mar;32(3):237-46.
  3. Powell MJ, Froggatt K, Giga S. Resilience in inpatient palliative care nursing: a qualitative systematic review. BMJ Support Palliat Care. 2020 Mar;10(1):79-90. doi: 10.1136/bmjspcare-2018-001693. Epub 2019 Feb 26.
  4. Hicks MM, Conner NE. Resilient ageing: a concept analysis. J Adv Nurs. 2014 Apr;70(4):744-55.
  5. Parkinson M, Carr SM, Rushmer R, Abley C. Investigating what works to support family carers of people with dementia: a rapid realist review. J Public Health (Oxf). 2017 Dec 1;39(4):e290-e301. doi: 10.1093/pubmed/fdw100.
  6. Zanatta F, Maffoni M, Giardini A. Resilience in palliative healthcare professionals: a systematic review. Support Care Cancer. 2020 Mar;28(3):971-978. doi: 10.1007/s00520-019-05194-1. Epub 2019 Dec 6.
  7. Teahan Á, Lafferty A, McAuliffe E, Phelan A, O'Sullivan L, O'Shea D, Fealy G. Resilience in family caregiving for people with dementia: A systematic review. Int J Geriatr Psychiatry. 2018 Dec;33(12):1582-1595. doi: 10.1002/gps.4972. Epub 2018 Sep 19.
  8. Cross AJ, Garip G, Sheffield D. The psychosocial impact of caregiving in dementia and quality of life: a systematic review and meta-synthesis of qualitative research. Psychol Health. 2018 Nov;33(11):1321-1342. doi: 10.1080/08870446.2018.1496250. Epub 2018 Sep 27.