An integrative review of resilience among nursing students in the context of nursing education

Abstract Aim This integrative review aimed to examine empirical research on resilience among nursing students in the context of nursing education. Resilience helps nursing students handle challenges, such as changing learning styles and experiencing their first clinical practice. Design An integrative review. Methods The search terms focused on resilience and health in nursing students and nursing education. The database used in this review were CINAHL Plus, PubMed and MEDLINE. The Mixed Methods Appraisal Tool appraised the studies' quality. Results This study explored 52 records and revealed three current research focuses related to nursing students' resilience: (1) the concept and description of resilience, (2) the characteristics affecting resilience and (3) the mediating role of resilience in maintaining holistic health. Recommendations include adding a resilience topic to the nursing curriculum, providing resilience enhancement programs, examining the relationship between resilience and holistic health and exploring the influence of resilience about global health crises. Public Contribution Resilience among nursing students plays a vital role in helping them to overcome adversities during their nursing education. Additionally, after graduation, nursing students can continue contributing to society as resilient Registered Nurses in the future.

negative challenges and adversities in life (Anderson et al., 2019;Baltacı, 2021). In addition, the concept of resilience as a process of adaptation is associated with what Nordenfelt (2014) has described as the second-order ability of a person to achieve their vital goals in the given or acceptable circumstances.

| BACKG ROU N D
Transitioning from adolescence to adulthood is a challenging part of life for nursing students as they have to face new and unexpected challenges, such as increased use of digital tools in the classroom and clinical education and changing timetable of clinical practice (Agu et al., 2021;Aslan & Pekince, 2021;Huang et al., 2020;Sveinsdóttir et al., 2021). Nursing students have to deal with new experiences both in the classroom and in clinical education, such as being challenged by new pedagogy and taking care of real patients for the first time during the first clinical practice. They must adapt to the higher education system (which sometimes requires that they live away from their families), deal with the high expectations of academic achievement and face new peer pressure challenges (Hollenbach, 2016;Olsen, 2018;Patton et al., 2016;Shearer, 2016;Simpson & Sawatzky, 2020). During their education, more complex challenges may ascend, such as uncertainty of course deadlines, extended duration of clinical practice, being under a high level of stress and lockdown of their institutes during new emerging pandemics (Agu et al., 2021;Harries et al., 2021;Huang et al., 2020;Luberto et al., 2020, Roldán-Merino et al., 2022Usher et al., 2020).
Resilience is broadly recognized as one of the vital facets related to one's positive health (Phillips et al., 2019;Santrock, 2019).
A high level of resilience is advantageous for adolescents when they face the challenges and responsibilities of adulthood, especially when experiencing adverse circumstances (Graham, 2018;Phillips et al., 2019;Schönfeld et al., 2017). Several challenging problems may arise during the transition period for nursing students. First, the transition periods from adolescence to adulthood and from academic learning to clinical training may put them under a lot of pressure that can put their health at risk, especially their mental health (Phillips et al., 2019;Santrock, 2019). Furthermore, resilience has been recognized as essential for undergraduate and graduate nursing students (Jackson, 2018). Recent studies in nursing education have indicated the importance of resilience as a positive influence that can help nursing students deal with the adversities, such as the impact on their quality of life, increased level of academic burnout and psychological distress during the lockdown period of the severe pandemic (Cuartero & Tur, 2021;Guillasper et al., 2021;Labrague & Ballad, 2021;Sweeney, 2021;Usher et al., 2020).
Numerous studies have suggested that resilience could contribute to personal growth due to the experience of negative, challenging and difficult circumstances throughout one's academic years (Amsrud et al., 2019;Kaewmanee et al., 2018;Olsen, 2018;Sangon et al., 2018). However, most studies on resilience and health in nursing students have mainly focused on the relationship between resilience and psychological health or well-being (Alzayyat & Al-Gamal, 2014;Delgado et al., 2017;Miremadi, 2015;Patton et al., 2016). Thus, a need to explore the relationship between resilience and a more holistic understanding of health. In addition, understanding how resilience in nursing students is conceptualized in the context of academic learning and, more specifically, in clinical training would be valuable. Further research is also needed in this regard (Reyes et al., 2015a;Thomas & Revell, 2016).
Two previous reviews related to resilience in nursing students provide key information on the general concept of resilience and some factors that can affect it in nursing students, especially in the context of clinical education Reyes et al., 2015a;Thomas & Revell, 2016). However, the definitions and concepts of resilience have changed over time and are commonly clarified according to specific populations (Stephens, 2013). Although there is a growing amount of research on resilience in nursing, a clear explanation of resilience in nursing students remains limited (Reyes et al., 2015b). Empirical studies on resilience have led researchers in the nursing field to examine the phenomenon in the nursing discipline, especially in the context of new and critical challenges that have emerged in nursing education, such as the recent trend of nursing studies on the effects of the COVID-19 pandemic (Agu et al., 2021;Cygan et al., 2021). The variation in definitions and conceptual descriptions of resilience in nursing and nursing education may create confusion or ambiguity for researchers. Therefore, the concept of resilience needs to be clarified in the context of nursing education.
This integrative review aimed to investigate empirical research on resilience among nursing students in the context of nursing education. The purpose of the integrative review was to answer the following research questions: 1. How is resilience among nursing students conceptualized in the context of nursing education in empirical research? 2. What may impact resilience in nursing students in the context of nursing education? 3. How is resilience promoted in nursing students in the context of nursing education?

| DE S IG N
In this study, Whittemore and Knafl's framework of integrative review method was used to analyze and synthesize both quantitative and qualitative publications about resilience in the context of nursing students (Whittemore & Knaft, 2005). The integrative review method allowed for the consideration of empirical research related to resilience in nursing education. Whittemore and Knafl's framework for data collection, analysis and synthesis consists of five stages: problem identification, literature search, data evaluation, data analysis and presentation.

| Literature search
The literature search was conducted using the following databases: CINAHL Plus, PubMed and MEDLINE, with support from a librarian at Mälardalen University. The keywords used in the search included the terms resilience, resiliency and health, along with the following terms: nursing students, student nurses, nursing education, clinical practice and clinical education. Publications were included if (a) the findings addressed resilience in nursing students, (b) participants in the studies were nursing students, (c) the study design was empirical, (d) the content was written in English and (e) the date of publication was between January 2011 and December 2021.
The reasons for choosing publications after January 2011 were to isolate the most recent literature addressing the research questions and to review the empirical studies that best reflected the recent issues related to resilience in nursing education. Publications were excluded if (a) they focused on resilience among other populations, such as other healthcare students, new nurse graduates, school nurses and nurse educators; (b) they discussed resilience as an implication rather than part of the study findings; (c) they were not empirical research studies, such as discussion and review papers; (d) they were unpublished dissertations and theses; (e) they could not be accessed in fulltext form and (f) they did not focus on nursing education.
The search strategy was carried out, documented and illustrated, as shown in Figure 1 (PRISMA flow diagram of the literature search, available to view in the online version), based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). A total of 1246 records were retrieved. Additional records identified through other sources (e.g., websites and organizations) were not included in this integrative review.
The topics of the 1246 records were primarily reviewed to screen for duplication of the studies, after which some duplicate articles were removed. A total of 714 abstracts were reviewed to search for relevance based on the inclusion criteria. Next, 585 records were excluded for not focusing on resilience in nursing students, not being original research articles, or addressing resilience as an implication or intervention rather than as part of the study findings; hence, these were excluded from the review. The remaining 129 records were assessed for eligibility, of which 77 were excluded for reasons such as not focusing on nursing students, not being related to nursing education and not being empirical research studies. Finally, 52 publications consisting of 41 quantitative studies, nine qualitative studies and two mixed methods studies met the inclusion criteria and were included in the data analysis of this integrative review.

| Data evaluation
Records included in the final sample were appraised for quality using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018). The MMAT is a critical tool for the appraisal stage of reviews that includes qualitative, quantitative and mixed methods studies. The tool assesses the methodological quality of five types of studies: qualitative research, randomized controlled trials, nonrandomized studies, quantitative descriptive studies and mixed methods studies (Hong et al., 2018). The 52 included studies were evaluated for quality based on the MMAT checklist. The characteristics and summaries of the included studies are illustrated in Table 1 (Characteristics and summary of included studies, available to view in the online version).

| Data analysis
The final studies selected for the review were empirical in nature.
The literature included a variety of study designs, such as descriptive, correlational, longitudinal, mixed methods, participatory action research, grounded theory and phenomenological. Generally, evaluation is more complex with various methodologies (Whittemore & Knafl, 2005). The research questions guided the analysis of the 52 articles, and the studies were compared and analysed for similarities and differences. Data with similar contexts were assembled. The four steps of data analysis, including data reduction, data display, data comparison and conclusion drawing and verification, were applied to obtain mutual themes and patterns and ensure the findings' rigour.

| E THI C S
Research Ethics Committee approval was not required for this study.

| General characteristics of the included studies
The 52 included studies were from 19 countries, including Australia, nursing students and other health students from different disciplines. However, the majority of participants in these four studies were undergraduate nursing students, with a total of 1345 participants. The number of postgraduate nursing students was 103, and 250 students from other disciplines were included as participants.
In summary, 16,046 undergraduate nursing students participated in the included studies.

| Concepts and descriptions of resilience in nursing students
Resilience has been viewed as an ability or process and a psychological trait. Among most included studies, concepts and descriptions of resilience in nursing students were broadly defined with existing concepts and definitions of resilience. Only three studies specifically provided definitions of resilience, while 13 articles did not mention a specific definition. Froneman et al. (2016) defined resilience as the ability of both nursing educators and students to effectively cope with stressors throughout their academic years. In contrast, Keener Smith Vestphal et al., 2020;Wang et al., 2021;Yıldırım et al., 2021). Several studies specifically mention resilience in nursing students as the ability to successfully handle academic stressors and attain academic success (Abiola et al., 2017;Beauvais et al., 2014;Chow et al., 2018;Chow et al., 2020;Hwang & Shin, 2018;Ozsaban et al., 2019;Wang et al., 2021).
Additionally, resilience was addressed as contributing to health conditions and well-being in nursing students Eaves & Payne, 2019;Elzohary et al., 2017;Hamadeh Kerbage et al., 2021;Ríos-Risquez et al., 2016;Serçe et al., 2021 andSpurr et al., 2021). Moreover, resilience was connected to the personal growth of nursing students, as they can learn from overcoming adversities and gain a positive outlook for their future (Hasson et al., 2021;Liang et al., 2019;Lopez et al., 2018). Among the included studies, resilience was described as an important trait or essential characteristic of nursing students. Resilience was described as a
Referring to the interpersonal characteristics reported in the included literature, social support was identified in eight studies as an essential factor that can affect nursing students' resilience, with students who received social support being reported to have higher resilience levels (Clohessy et al., 2019;Dong et al., 2021;Elzohary et al., 2017;Ertekin Pinar et al., 2018;Hwang & Shin, 2018;Lekan et al., 2018;Ozsaban et al., 2019;Yıldırım et al., 2021). In addition, mindfulness was another positive influencing factor for developing resilience in nursing students (Ching & Cheung, 2021;Chow et al., 2018;Mathad et al., 2017). Some studies have highlighted that resilience can also be affected by and developed through academic learning, clinical practice and skills training (Ertekin Pinar et al., 2018;Hasson et al., 2021;Liang et al., 2019).

| Mediating role of resilience in nursing students' health
Resilience has played a vital role as a mediator between the various factors influencing nursing students' health and well-being. Devi et al. (2021) indicated that resilience is a vital mediator of psychological health and factors such as stress, anxiety and depression in the context of experiencing clinical practice. Kong et al. (2016) identified resilience as an important mediator between emotional intelligence and clinical communication ability in nursing students during clinical training. During the COVID-19 pandemic, another study showed that resilience mediated between life satisfaction and well-being among nursing students (Labrague, 2021).
Additionally, resilience can affect factors that influence nursing students' lives and their contributions to their nursing studies.
Life satisfaction was shown to be affected by resilience in studies by Elzohary et al. (2017), Kim (2019) and Labrague (2021). A low level of resilience is associated with high academic stress in others (Mcdermott et al., 2020;Ozsaban et al., 2019;Van Hoek et al., 2019). Moreover, a high resilience level was reported to affect several factors in nursing students, including higher satisfaction and achievement in clinical practice (Lopez et al., 2018); less or no intention to drop out (Eaves & Payne, 2019;Van Hoek et al., 2019); having posttraumatic growth (Li et al., 2014;Yıldız, 2021) and overcoming bullying during their nursing education (Mott, 2014).

| DISCUSS ION
This integrative review revealed that the current scope of knowledge related to resilience among nursing students in the context of nursing education focuses on three main aspects: (1) the concept and description of resilience as either an ability, a process, or a psychological trait; (2) the characteristics affecting nursing students' resilience and (3) the important role of resilience as a mediator in helping nursing students maintain their holistic health.
The concept of resilience among nursing students has been generally mentioned in most literature as a psychological notion.
Although nursing students' resilience was mentioned as being associated with nursing students' health, such an understanding of the concept has not yet been clearly described in the context of nursing education. Furthermore, a model with a specific definition of resilience has not been employed and tested in the resilience literature (Stephens, 2013), and a specific description of resilience related to nursing education should be clearly defined in the literature (Thomas & Revell, 2016).
Resilience among nursing students with diverse demographic backgrounds in terms of age, gender and living conditions was found to differ. Specifically, this integrative review revealed that older Age was associated with all students' resilience, though some factors affected resilience among students from different disciplines. Among nursing students, gender and financial assistance were associated with resilience, whereas the year of study was indicated as significant among medical laboratory science students and having a paid job was reported among optometry students. In addition, all nine predictors in the study affected resilience among nursing students Nursing instructors and clinical preceptors should work together to enhance resilience in nursing students and other healthcare students. The enhancement of resilience could help them with personal growth and professional development Semi-structured interview Two main themes were revealed: (1) stressors arising from the students aligning their expectations with the demands of the clinical placement and (2) coping as a process of fitting into the ward culture. High resilience and low burnout levels among nursing students were associated with self-directed goals and coping by using self-regulation strategies. In contrast, low resilience and high burnout were related to external orientation and self-blame strategies The authors recommended three approaches to help nursing students during their clinical practice: (1) offering interventions to empower nursing students to fit into the clinical environment, (2) inspiring engagement in selfreflection and (3)  The findings revealed a relationship between resilience, stress and burnout. Stress predicted disengagement and emotional exhaustion was predicted by stress and year of study. A high level of stress and a low level of resilience predicted the intention to quit a midwifery program. Resilience was indicated as an essential factor to help reduce the choice to quit. Moreover, resilience did not affect burnout among students but helped preserve their interest in the profession and prevented them from leaving their education Resilience may be helpful for nursing students to continue with their education while they are working in the nursing profession The findings showed a positive relationship between psychological resilience, self-confidence and problem-solving skills. Age was associated with selfconfidence and psychological resilience, whereas living area was associated with self-confidence and problem-solving skills. In addition, perceived social support was related to psychological resilience and problem-solving skills and monthly income was related to psychological resilience Preventive programs regarding factors affecting students' resilience, self-confidence and problem-solving skills were recommended. Furthermore, future studies that examine low levels of resilience, selfconfidence and problem-solving skills based on different years of study should be considered Collet-Lester Fear of Death Scale (CLFODS)/ Resilience Scale (ER-14)/demographic form Fear of death among nursing students was reported at medium to high levels throughout all academic years and was associated with their age. In addition, the study year was related to nursing students' resilience levels Although this study revealed that fear of death was not related to resilience among nursing students, the authors emphasized the importance of resilience in clinical education for nursing students World Café Method/content analysis The findings revealed five main themes; (1) teaching-learning environment, (2) educatorstudent interaction, (3) educator qualities, (4) staying resilient and (5)  The findings showed an association between burnout, emotional exhaustion and self-efficacy with resilience and psychological health in nursing students. In addition, the study revealed the moderating role of resilience in psychological health in cases of emotional exhaustion The measurement of appropriate training for nursing students was recommended. Moreover, future research investigating the relationship between resilience and academic burnout and the effect of resilience on psychological health is crucial

Connor-Davidson Resilience Scale (CD-RISC)/ Warwick-Edinburgh Mental Well-Being Scale (WEMWBS)/demographic form
There were no significant differences in resilience level based on age, gender and year of study. However, nursing students' academic performance affected their resilience, such that nursing students with higher grade point averages (GPA) were reported to have higher resilience levels. Moreover, a positive relationship between resilience and mental wellbeing was reported among nursing students during the pandemic Nursing students' assessment of resilience and mental well-being should be carried out through academic support by nursing educators and preceptors

Connor-Davidson Resilience Scale (CD-RISC)/ narrative reflection/demographic Form
Resilience levels were higher in employed nursing students than those unemployed. In addition, resilient nursing students' resilience level is sorted to be higher than those of others. Three main themes were identified: (1) fear of the virus, (2) isolation and (3)  Future studies are recommended to understand better the factors affecting nursing students' resilience and how they can be improved. Better theoretical models related to resilience among nursing students should be developed and evaluated

In-depth individual interviews
The basic social process associated with the understanding and enactment of resilience in nursing students was identified as "pushing through," which they employed to handle adversities during their education. Resilience can be learned and developed, as it is viewed as a dynamic and contextual process instead of a static trait or personality characteristic Future research focusing on theory development within the context of different types of nursing education programs and diverse cultural backgrounds is recommended. In addition, the findings of this study addressed the need to integrate the topic of nursing students' resilience into the nursing curriculum  . Furthermore, resilience is related to a specific type of personality in nursing students (Škodová & Bánovčinová, 2018).
Intrapersonal characteristics in nursing students, such as high selfefficacy, being positive, high self-confidence, high self-compassion The effects of academic motivation on resilience and post-traumatic growth in nursing students were found. Additionally, resilience was identified as a mediator between academic inspiration and posttraumatic growth A program enhancing post-traumatic growth through reinforcing intrinsic motivation and resilience should be developed and integrated into the nursing curriculum. Future research should explore resilient nursing students' characteristics and the relationship between academic motivation and nursing retention rates in maintaining and enhancing nursing students' resilience. During the COVID-19 pandemic, several studies indicated the importance of the direct effect of social support on nursing students' resilience (Cuartero & Tur, 2021;El-Sayed et al., 2021;Warshawski, 2022), and a mediated role of resilience between social support and quality of life among nursing students (Pineda et al., 2022). Female nursing students were reported to perceive more social support than male nursing students (Cuartero & Tur, 2021). In addition, a high level of resilience in nursing students was reported to be associated with adequate social support (Caton, 2021). Similarly, a high level of resilience was associated with perceived social support among university students (Hamdan-Mansour & Hamdan-Mansour, 2014) and adolescents (Hidayat & Nurhayati, 2019). Moreover, social support was a significant predictor of resilience among adolescents (Çiçek, 2021). Students at the higher education level with a high level of resilience were found to be more likely to successfully reach out for support (Md Khalid, 2021).
Nursing students' resilience can be defined as the ability to adapt to difficult situations and obstacles. Resilience can be viewed as the ability to recover quickly from an adverse, challenging circumstance to accomplish vital goals. Nursing students who have high resilience seem to be able to connect with their inner strengths, which helps them bounce back from negative challenges during their nursing education. The COVID-19 pandemic is one example of negative encounters impacting nursing students' stress levels (Gallego-Gómez et al., 2020). Therefore, resilience can help nursing students maintain their holistic health and well-being and cope with stress during their nursing education. Bouncing back can be a valuable means to maintaining one's holistic health (Nordenfelt, 2014). In addition, Ozsaban et al. (2019) pointed out that nursing students with high levels of resilience will be more likely to successfully recover from unpleasant experiences that can affect their physical, mental and social health, which they may encounter in both classrooms and clinical placements. A recent study on resilience in nursing students during the COVID-19 pandemic defined resilience in nursing students as the ability related to successful adaptation to life-threatening conditions (Mohammadi et al., 2022).

| Limitations
The findings of this review may be limited by the inclusion criteria applied to the studies found in a specific database. The included studies were also limited to those published from 2011-2021. Since only empirical studies on resilience in nursing students written in English were reviewed, it is possible that studies in other languages could have improved our understanding of nursing students' resilience.

| CON CLUS ION
This integrative review explored and analysed the scope of knowledge related to resilience among nursing students in the context of nursing education. Three key themes were highlighted, which include the concept and description of resilience, the characteristics of nursing students that affect their resilience and the vital role of resilience as a mediator of holistic health in nursing students.
Furthermore, this integrative review has some critical implications for nursing research. First, stakeholders in nursing education should add the topic of resilience to nursing curricula and provide special training to enhance resilience in nursing students. Future research should focus on exploring the connection between resilience and holistic health in nursing students. Moreover, research focusing on the relationship between nursing students' resilience and their demographic, intrapersonal and interpersonal characteristics would be a valuable contribution to nursing education.
The findings of this integrative review have some implications for nursing education. Nursing educators, nursing preceptors and policymakers are encouraged to add the topic of resilience to the nursing curriculum to improve nursing education. In addition, specific programs related to nursing students' intrapersonal characteristics to enhance resilience should be provided as brief training sessions before they begin their clinical education. Furthermore, the interpersonal characteristics of nursing students, such as social support, must be considered throughout their nursing education. This integrative review also suggests that future research on resilience and holistic health among nursing students needs to be conducted.
Specifically, more research related to resilience in nursing education should focus on exploring the relationship between resilience and the characteristics that affect its development among nursing students. Furthermore, future research on the influence of resilience in nursing students in the context of global health crises, such as emerging infectious diseases, may significantly contribute to nursing education and the nursing profession.

AUTH O R CO NTR I B UTI O N S
PA has assumed overall responsibility for the study. However, MA, AL, MR and JH have contributed to the design and planning of the study, writing of the manuscript, critical discussions and revisions.
PA was responsible for collecting, mapping and initially analysing the data. The final analysis of the data and the framing of the results were performed together by all authors. PA revised the final manuscript and completed it for submission.

ACK N OWLED G EM ENTS
The authors would like to thank Mälardalen University and

Praboromarajchanok Institute, the Ministry of Public Health
Thailand for financial support.

FU N D I N G I N FO R M ATI O N
The study was funded by Mälardalen University and Praboromarajchanok Institute, the Ministry of Public Health Thailand.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data openly available in a public repository that issues datasets with DOIs.