Resilience is a dynamic process that allows an individual to “bounce back” from adverse circumstances or conditions.1 It is the ability to achieve, retain, or regain a level of physical or emotional health after illness or loss.2 Resilience, a component of an individual's personality, is observed in individuals through their adaptive behavior.3 Resilience is developed through functioning in the presence of adversity such as chronic disease and is enhanced by the environment such as family and support systems. Resilience is comprised of 3 sets of attribute pairs: competence and adversity, assets and risks, and protective processes and vulnerabilities.4 The attribute pairs of resilience are depicted in Figure 1. The attribute pairs of assets and risks and protective processes and vulnerabilities accompany each other and may be cumulative or may balance each other out.4
While children and adolescents have been the target of most of the resilience research, researchers have recently become interested in the impact of resilience on aging individuals. Resilience can impact health and well-being and is an important aspect of the older individual's physical and psychological adjustment and adaptation to the aging process.1,5 Therefore the attributes of resilience may be important to successful aging and of interest because these attributes may be developed.6 Assessment of resilience may provide physical therapists with additional knowledge of how to help patients to recover and thrive.
Spirituality is known to positively impact resilience.7 Spirituality, an entity that expands the concept of religion to an understanding of answers to ultimate questions about life, meaning and relationship to the sacred or transcendent, is inherent in the religious such as Roman Catholic nuns. Thus, nuns may have a propensity to be resilient, as spirituality can be considered a personal (human) asset.
Some studies have found that older adults who self-reported good to excellent physical health tended to have high resilience levels.8–14 Also, individuals who self-reported few or no depressive symptoms or good to excellent mental health also had high resilience levels.10,13–16 For example, a study of Swedish older adults found women, but not men, who reported better mental health had higher resilience levels.17 Another study found support for the association of resilience with depression in older adults; however, with increasing age resilience seemed to lose importance with regard to late-life depression.18
Participation in exercise has also been associated with resilience possibly through enhancing successful aging and recovery.6 While evidence supports these positive relationships between resilience and exercise and self-perceived health status, the relationship between actual physical performance measures and resilience is not well established. High function as measured by physical performance measures may provide a protective effect that facilitates recovery if adversity is encountered or decreases the likelihood of functional decline, thus influencing resilience. For example, in a study of community-dwelling older adults, high resilience was associated with high, self-reported physical activity levels and strong hand grip.10 Strong hand grip was associated with less functional limitation,19 mortality, and morbidity.20
Physical performance measures such as gait speed can serve as a proxy for self-reported health status and have been found to predict survival.21 Therefore, improved gait speed may indicate resilience and thus the ability to recover from a stressful event such as surgery or an injurious fall.22 Because specific physical performance measures were linked to better outcomes and resilience may enhance recovery, evidence is needed to determine if there is an association between resilience and physical performance measures. Using a holistic perspective that includes resilience may provide additional information for physical therapists.23
The purpose of this research study was to investigate the resilience level in a convenience sample of older women who were Roman Catholic nuns. The relationships of resilience with specific physical performance measures, self-perceived physical and mental health status, and depressive symptoms were also explored. We hypothesized that this sample of Catholic nuns would have moderate to high resilience levels because of their inherent spirituality. Furthermore, we hypothesized that those with higher resilience scores would perform better on physical performance measures, have fewer depressive symptoms, and report better physical and mental health than those with lower resilience scores.
A pilot program called Transitions was developed to promote wellness among aging nuns at a local convent as they transitioned into late adulthood. The program was initiated with a health fair delivered at 2 different times, about 8 weeks apart. Data from the 2 combined health fairs were collected on 56 volunteer nuns aged 44 to 94 years beginning with self-report questionnaires followed by physical performance tests. Physical therapists and physical therapy students administered the physical performance measures after reviewing test procedures and practicing test administration to assure consistency in test administration. Each performance measure constituted a station in the circuit-style health fair. The data were collected in random order with the same individuals administering a single test. The testing took about 1.5 hours for each person. All tests were voluntary. University Human Subjects Review Committee provided approval for this study.
Resilience was measured with the 14-item Resilience Scale (RS-14).24 The RS-14 is a revised version of the original 25-item Resilience Scale (RS-25).3 The RS-25 was developed through a qualitative study of older women who were identified as being resilient. Five themes emerged in this group of resilient older adults: equanimity, self-reliance, perseverance, meaningfulness of life, and existential aloneness. These 5 themes were incorporated into the RS scale.16 The RS-14 uses a Likert scale with 7 possible responses for each item ranging from 1 (strongly disagree) to 7 (strongly agree). Total scores range from 14 to 98. Scores greater than 90 indicate high resilience, scores from 61 to 89 indicate moderately low to moderate levels of resilience, and scores of 60 and higher indicate low resilience.25 Reliability and validity of the RS have been well established in various populations including older adults.6,16,26 In addition, the RS and RS-14 were found to be strongly correlated (r = 0.97, P < .001) and the reliability for the RS-14 ranged from 0.91 to 0.93 (α coefficient).25
Health status was measured using the short-form revised health survey (SF-12v2).27 The SF-12v2 is a norm-referenced self-reported measure of health status. The SF-12v2 has 2 health summary components that include the Physical Component Summary (PCS) and the Mental Component Summary (MCS). The reliability and validity of the SF-12 is well documented.27 It is a commonly used instrument to measure self-perception of health status in the presence of chronic disease.
Depressive symptoms were measured using the 9-item Patient Health Questionnaire (PHQ-9).28 The PHQ-9 uses a Likert scale with 4 possible responses for each item ranging from 0 (not at all) to 3 (every day). Scores range from 0 to 27 with 1 to 4 indicating minimal depression, 5 to 9 indicating mild depression, 10 to 14 indicating moderate depression, 15 to 19 indicating moderately severe depression, and 20 to 27 indicating severe depression. The PHQ-9 demonstrated strong internal consistency and test-retest reliability in a large sample of adult men and women, and showed good construct validity in a subsample of adults older than 65 years.29
The Short Physical Performance Battery (SPPB) was used to assess physical function.30 The balance portion includes standing with feet side-by-side, in semi-tandem, and full tandem for a total of 10 seconds in each position beginning with side-by-side and progressing to tandem stance as able. Usual gait speed more than 4 m with 2 m acceleration and deceleration distances was measured over 2 trials with the fastest time recorded of the 2 trials. Assistive devices were permitted, if needed. The chair rise test is the time it took to stand completely erect from a standard chair (17 in) 5 times without use of arms. Each task was scored from 0 to 4 depending on performance according to test protocol.30 Scores from individual items were summed to create a composite score with a potential range from 0 to 12. Higher scores indicate higher functioning. The SPPB score is an objective measure of mobility disability.31 Fast gait speed, which is not a measure within the SPPB, was measured similarly to usual gait speed except the participants were instructed to walk the 4 m as fast as possible with the fastest time recorded of the 2 trials.
Because our purpose was to focus on relationships of older participants, observations on those younger than 55 years (n = 2) were excluded from analyses. Because of missing items in the RS-14, ratio imputation was used to replace missing values for observations missing fewer than half of the items in that scale.32 Ratio imputation uses a highly correlated item within the same instrument to estimate the value of a missing item. Data were imputed for 5 observations, while 6 observations missing more than half of the scale items were excluded from analyses of this variable. The 14-items were summed to derive a total resilience score. For the 9-item Depressive Symptoms Scale (PHQ-9), 5 observations with more than 2 missing items were scored as missing for the variable. Scores from observations with nonmissing items, or missing 1 item were summed to derive a total depressive symptoms score.28 The SF-12 physical and mental component scores were derived using the recommended method.27
Descriptive statistics for demographic and clinical variables, physical performance tests, and self-rated variables were computed using means, SD, and medians. Observations were stratified according to missing and nonmissing values for self-rated SF-12 scales, depressive symptoms, and resilience scales. These groups were compared using independent-sample t tests to assess whether bias may have been introduced by excluded observations with missing data in subsequent analyses. Sample means of selected physical performance measures were compared with available, age-stratified, published norms,33,34 using 1-sample t tests, to determine whether the sample differed in those respects from a community-dwelling adult population. As the variables in the data set were generally not Gaussian, Spearman correlations were used to determine associations between resilience and other self-rated characteristics as well as physical performance measures. For all analyses, alpha was set at .05.
Fifty-four participants aged 55 years and older were included in analyses. All participants who responded to the query regarding ethnic origin (n = 50) indicated white, not Hispanic ethnicity. Descriptive statistics for other clinical and demographic characteristics are reported in Table 1. The median age was 72 years. Participants reported a median of 5 prescription medications and a median of 2 chronic diseases. The most commonly reported chronic disease was arthritis (57.1%), followed by diabetes (28.6%), other (26.8%), heart disease (19.6%), lung disease (12.5%), and cancer (5.4%).
Table 2 includes descriptive statistics for self-rated variables, including resilience, depressive symptoms, and SF-12 PCS and MCS. Summary statistics for demographic and clinical characteristics and physical performance measures in participants with missing and nonmissing values for self-report measures are presented in Table 3. There were no significant differences in these values between those with missing and complete data for self-report measures.
Table 4 displays the comparisons of sample physical performance tests with published norms according to age group.33,34 For all age strata, there were no significant differences between the sample means and published norms for usual gait speed, fast gait speed, and chair rise scores.
Bivariate associations between resilience and self-rated depression score, SF-12 PCS and MCS, total SPPB score, and fast gait speed are reported in Table 5. Spearman correlation coefficients were significant for comparisons of resilience with total Depressive Symptoms Score, SF-12 PCS, and fast gait speed. The association between resilience and usual gait speed approached statistical significance. The strongest association was observed between resilience and the SF-12 PCS measure.
The relationship between resilience level and specific physical performance measures, perceived health status, and depressive symptoms were investigated in a sample of older Catholic nuns. The mean score of the sample on the RS-14 was 82.6, indicating that this sample of nuns had, on average, moderate resilience, supporting our hypothesis that this sample of nuns would have moderate to high resilience. These resilience scores are similar to the mean (SD) resilience score of 84.4 (10.2) in a large sample of middle-aged and older adults.25
Participants who reported more depressive symptoms were found to have lower resilience levels. This relationship is consistent with previous studies and supports our hypothesis that resilience scores would be correlated with depressive symptoms.10,15,18 In addition, we found that good physical health and fewer depressive symptoms were associated with higher resilience levels. The lack of association between resilience and the mental health component of the SF-12 is contrary to other authors' findings.14,17 The mental health component of the SF-12 addresses the degree to which emotional problems impact daily life. Normative data from studies using the SF-12 indicate that participants in this study rated their mental health higher than women of similar ages in other studies.27 Older Catholic nuns may have a spiritual grounding that serves as protection and helps them feel mentally healthy. However, other factors could contribute to this and further study is needed.
Participants with higher resilience levels reported better physical health. Because better physical health is a protective asset, this finding is not surprising.30,31 While the participants rated their physical health quite high; some of their scores on physical performance measures indicated a risk for mobility disability. The mean SPPB score of 10.1 indicates an increased likelihood (4.2x) in developing mobility disability.31
Only fast gait speed of the physical performance measures collected correlated with resilience. While this relationship was not strong (r = .319), it was statistically significant (P = .027). Fast gait speed may be a measure of reserve, a possible protective factor,35,36 and thus an expression of resilience. It may be that physical performance measures that reflect common tasks such as walking at one's usual pace and rising from a chair do not challenge an individual sufficiently and thus do not provide a protective effect as the reserve associated with fast gait speed. Further research is indicated to understand this issue.
Therapists' knowledge and awareness of resilience may aid in clinical decision making. For example, if an individual in an inpatient facility presents with low resilience, the therapist may anticipate the patient might be more vulnerable to internal and external stressors. This individual may require more team awareness and intervention to provide an experience that is constant and supportive, and relatively free from change. Alternatively, a therapist may ask the health care team to explore sources of low resilience that may be amenable to intervention, such as a financial or living situation. High resilience may indicate the individual in an inpatient setting may be particularly adept at problem solving, requiring only oversight on the part of the health care team. In fact, it is plausible that individuals with high resilience may not appreciate more than courteous oversight, feeling quite capable of resolving specific challenges.
A limitation of this study was that the participants self-selected to participate in the Transitions testing. Approximately 150 nuns were eligible to participate in the program and only 56 chose to participate. Reasons for nonparticipation were not explored. It is conceivable that those with less frailty, fewer depressive symptoms, and better health chose to participate. Missing data for resilience, depressive symptoms, and the SF-12 measures may have introduced bias. The lack of statistically significant differences in demographic, clinical, and physical performance variables in observations with missing and nonmissing data argues against this, however. In addition, this sample included only Catholic nuns. Although participants' physical performance measures were not significantly different from published norms in community-dwelling women, generalization to the broader population of older women should be made with caution. A further limitation is the cross-sectional design of this study. Because of this, temporal or predictive relationships between variables cannot be established. Future research employing longitudinal designs is needed to elucidate the predictive validity of the variables studied, as well as improvement or deterioration in the physical and emotional capacities of these older nuns.
The participants in this study who had higher resilience levels were found to have fewer depressive symptoms, better subjective physical health, and faster gait speeds, partially supporting our hypotheses. Facilitating recovery and preventing mobility disability in older women is of great importance to physical therapists. Because physical and emotional well-being are closely related, it is reasonable for physical therapists to consider both resilience and physical performance measures when attempting to identify older women at risk for poor outcomes. Members of the health care team need to work together to help in identifying factors such as resilience that affect older adults' ability to maintain physical function and to recover from injury or surgery. A comprehensive assessment of the older adult patient is needed when rehabilitation is initiated and communication between disciplines is essential to facilitate recovery. While limitations of this study have been recognized, we hope that physical therapists have an increased awareness of resilience and the potential connection resilience may have in helping older adults recover from a physical injury.
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Resilience; Gait Speed; Physical performance measures
Copyright © 2012 the Section on Geriatrics of the American Physical Therapy Association