Resilience in Older People: A Concept Analysis

(1) Background: Resilience has been presented as a potential protective factor to be promoted in difficult experiences in older people. However, further clarification of the concept of resilience for this population is required, as this is of critical interest for nursing care. (2) Aim: To develop the concept of resilience in older people to establish the elements that refer to the nursing outcome. Personal resilience (1309) from the Nursing Outcomes Classification (NOC), specifically in older people. (3) Methods: Concept analysis using Beth Rodgers’ evolutionary model. The attributes, antecedents, consequents, and empirical elements were described in the integrative review, with searches in PubMed, CINAHL, PsycINFO, LILACS, and Embase databases. A total of 2431 citations have been identified, and 110 studies were included. (4) Results: The concept of “resilience in older people” is composed of two attributes, available resources and positive behaviors, and is defined as positive attitudes of older people with the assistance of resources available from experiences of adversity. Conclusion: This analysis and concept development of resilience in older people provided sensitive indicators for nursing care in the context of adversity, considering available resources and with positive attitudes during this phase of life span.


Introduction
In its evolution, resilience was initially established as an innate characteristic, a personal attribute experienced by individuals who succumbed to major fatalities [1].In current models, it is understood as a human potential to be developed during life, considering personal contexts, mechanisms, and abilities learned [2].Self-control, problem-solving, coping, determination, and wisdom are abilities in the face of life experiences and especially present in favorable contexts with robust social, family, and spiritual structures that reinforce resilience [3,4].
In health, understanding the concept of resilience is critical due to its role in coping and adaptation in the face of adversity [3].Different stages of life span lead to the development of resilience through critical experiences, such as illness, disability, living with violence, prejudice, and wars [4,5].The more resilient, the more adaptive outcomes and less impact on health, considering the biological, psychological, and social aspects [3,6].
Nursing recognized worldwide for its role in health care, is responsible for evaluating and intervening in health promotion, disease prevention, treatment, rehabilitation, and recovery actions.In these contexts, nurses are trained to develop care plans based on the assessment of global and individualized needs, which mainly serve vulnerable groups in society [7].
As for 2021 global demographics, older people represent 13.5% (1 billion) [8] of the population.Interestingly, the dynamic character of resilience is expressed by more or less

Materials and Methods
The evolutionary model by Beth Rodgers [15] of concept analysis was used to develop "resilience in older people".Six steps determine the process: (1) identification of the concept of interest and associated terms; (2) selection of the appropriate field for data collection; (3) data collection and identification of the attributes of the concept, considering the interdisciplinary, sociocultural context and temporal variations (antecedent and consequent); (4) analysis of the concepts' characteristics; (5) identification of an example of the concept (if appropriate); (6) identification of implications, hypotheses for future development of the concept [12].This concept analysis was based on the procedures described for conducting an integrative review [16].

Identification of the Concept of Interest and Associated Terms
In this study, the concept of resilience related to ageing is developed under the health care approach for a sensitive outcome to nursing interventions.Thus, the concept of interest was defined as "resilience in older people", and the associated terms were:

Data Sources
We selected five databases: PubMed (National Library of Medicine National Institutes of Health) from Bethesda, MD, USA; CINAHL (Cumulative Index to Nursing and Allied Health Literature) from Ipswich, MA, USA; PsycINFO (American Psychological Association) from Washington, USA, considering only PsycArticles; LILACS (Latin American Caribbean Literature on Health Sciences) from São Paulo, Brazil, and Embase ® , Amsterdam, The Netherlands, with their controlled descriptors Medical Subject Headings (MeSH), Health Science Descriptors (DeCS), Entree Thesaurus and uncontrolled (keywords) combined using the Boolean operators "AND" and "OR" (Table 1).

Data Collection and Identification of Attributes, Antecedents and Consequents of the Concept
To achieve the objectives, the identification of the empirical elements proposing to evaluate the concept in the context of older people was also considered.
Initially, the guiding questions were defined using one of the variations of the acronym PICo (Population: people over 65 years of age; Interest: resilience; Context: ageing).The guiding questions were: What are the conceptual elements of resilience in older people?What are the measures that allow the assessment of resilience in older people?
As inclusion criteria, primary (experimental, observational, methodological, and analytical) and reflective studies, whose authors studied resilient characteristics in older people; research published electronically in Portuguese, English or Spanish; studies using samples of people aged 65 and over in any life situation or health condition were considered.No publications with time restrictions were considered.
The study selection process (Figure 1) was based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) [17].The study citations selected in the databases were imported to the software EndnoteWeb ® (access by: https: //www.myendnoteweb.com/EndNoteWeb.html,accessed on 1 August 2023) [18] to remove duplicates.Then, Rayyan ® (access by: https://rayyan.ai/,accessed on 1 August 2023) [19] was used to organize the readings of titles, abstracts, and full text and to screen the studies independently among the reviewers.
Initially, the guiding questions were defined using one of the variations of the acronym PICo (Population: people over 65 years of age; Interest: resilience; Context: ageing).The guiding questions were: What are the conceptual elements of resilience in older people?What are the measures that allow the assessment of resilience in older people?
As inclusion criteria, primary (experimental, observational, methodological, and analytical) and reflective studies, whose authors studied resilient characteristics in older people; research published electronically in Portuguese, English or Spanish; studies using samples of people aged 65 and over in any life situation or health condition were considered.No publications with time restrictions were considered.
The study selection process (Figure 1) was based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) [17].The study citations selected in the databases were imported to the software EndnoteWeb ® (access by: https://www.myendnoteweb.com/EndNoteWeb.html,accessed on 1 August 2023) [18] to remove duplicates.Then, Rayyan ® (access by: https://rayyan.ai/,accessed on 1 August 2023) [19] was used to organize the readings of titles, abstracts, and full text and to screen the studies independently among the reviewers.In August 2020, a total of 1988 studies were found in the databases, and 202 were removed for duplicates.According to the inclusion criteria, after evaluating the titles and abstracts, 117 studies were selected for full-text reading; 46 studies were excluded (21 did not mention the concept or measure of resilience; nine did not report older people; six were literature reviews; two were written in other languages; two were congresses' abstracts; two were dissertations; one was an editorial; one was an experimental study with animals; one was a concept analysis; one was unavailable for reading).After selection, 71 studies were included.
The literature analysis took more time than planned, aligned with the design of the concept of "resilience in older people", and the search was updated in December 2022.From August 2020 to December 2022, 443 studies were added, considering the five databases.Sixty-one duplicate studies identified by EndnoteWeb ® [18] and Rayyan ® [19] were removed.According to the eligibility criteria, 332 studies were excluded after titles and abstracts evaluation, and 11 studies were excluded in full-text reading, as eight focused on the variable correlated of resilience and three for not having concept and resilience assessment.In this update, 39 more studies were included; therefore, for concept development, the total was 110 (Figure 1).

Data Analysis
For the analysis and synthesis of the included studies, a spreadsheet was created in Microsoft Office Excel ® , containing information regarding the identification of the study (title, authors, year, country, and journal), the descriptors/keywords, the objective of the study, methodological aspects (design, sample characteristics, and study setting), and concept characteristics (substitute/related terms; attributes/definitions; antecedents; consequents; empirical elements).
Considering one of the purposes of the concept development, the attributes, antecedents, consequents, and empirical elements established the elements that make up the nursing outcome in the taxonomy of Nursing Outcomes Classification (NOC) [14].The correspondence [20] of the elements of the concept analysis with the elements of the taxonomy was considered as follows: the attributes corresponded to the definition and title of the nursing outcome, the antecedents, and consequents to the indicators of the nursing outcome, and the empirical elements to the measurement scale (Figure 2).abstracts, 117 studies were selected for full-text reading; 46 studies were excluded (21 did not mention the concept or measure of resilience; nine did not report older people; six were literature reviews; two were written in other languages; two were congresses' abstracts; two were dissertations; one was an editorial; one was an experimental study with animals; one was a concept analysis; one was unavailable for reading).After selection, 71 studies were included.
The literature analysis took more time than planned, aligned with the design of the concept of "resilience in older people", and the search was updated in December 2022.From August 2020 to December 2022, 443 studies were added, considering the five databases.Sixty-one duplicate studies identified by EndnoteWeb ® [18] and Rayyan ® [19] were removed.According to the eligibility criteria, 332 studies were excluded after titles and abstracts evaluation, and 11 studies were excluded in full-text reading, as eight focused on the variable correlated of resilience and three for not having concept and resilience assessment.In this update, 39 more studies were included; therefore, for concept development, the total was 110 (Figure 1).

Data Analysis
For the analysis and synthesis of the included studies, a spreadsheet was created in Microsoft Office Excel ® , containing information regarding the identification of the study (title, authors, year, country, and journal), the descriptors/keywords, the objective of the study, methodological aspects (design, sample characteristics, and study setting), and concept characteristics (substitute/related terms; attributes/definitions; antecedents; consequents; empirical elements).
Considering one of the purposes of the concept development, the attributes, antecedents, consequents, and empirical elements established the elements that make up the nursing outcome in the taxonomy of Nursing Outcomes Classification (NOC) [14].The correspondence [20] of the elements of the concept analysis with the elements of the taxonomy was considered as follows: the attributes corresponded to the definition and title of the nursing outcome, the antecedents, and consequents to the indicators of the nursing outcome, and the empirical elements to the measurement scale (Figure 2).

Characteristics of the Studies
A total of 110 were included (Table S1).Most were carried out in the United States of America (n = 37), Canada (n = 12), China (n = 10), and Brazil (n = 9), published between 1990-2022, with the majority (n = 39) between the years 2020-2022.There was a predominance of publications using a quantitative design (n = 66), as well as qualitative studies (n = 28), cohorts (n = 17), methodological studies (n = 8), and studies with an approach to older people in the context of life in the community (n = 38), in the presence of depressive symptoms (n = 5), under limitations, such as the risk for falls, visual impairment, bone fracture and diagnoses of Dementia and Stroke (n = 5), and in other situations of adversity, such as immigrants, widowhood, palliative care, holocaust, and others.After updating the database search, there were also studies reporting the resilience of older people in the context of the COVID-19 Pandemic (n = 8).This section may be divided by subheadings.It should provide a concise and precise description of the experimental results, their interpretation, and the experimental conclusions that can be drawn.

Surrogate and Related Terms
During the study analysis, other substitutes and related terms were identified, which may express similar ideas and characteristics, using different terminologies to represent the concept of interest [15].

Attributes
The attributes constitute the real definition of the concept, which can be represented by situations or words that adequately characterize the concept [15].

Consequents
Described as results, manifestations, or outcomes of the concept or phenomenon of interest [15], the consequences of resilience in older people, according to the literature, comprise the components of mental health (control of psychological symptoms and control of emotions) [11,22,23,38,40,

Empirical Elements
The empirical elements represent categories or classes related to the essential attributes in which the concept can be observed and that allow its operational definition [15].Some authors proposed to measure the concept of resilience in the context of life of older people, using scales and/or interventions and qualitative assessment.

Exemplar Case
To demonstrate the application and purposes of clarifying the concept of "resilience in older people" [15], an exemplary case was identified in the literature inserted in the context of older people's lives [131].". ..Mrs.W is a 75-year-old woman, widowed, who lives alone in her apartment after her husband died three years ago.She was admitted to a community hospital with chief complaints of falling at home and pain in her left knee.Her three children live in different states, and she has a female friend who is a neighbor in her apartment building, and they talk on the telephone at least twice a week.She has a degree in Music and enjoys playing the piano at her church.She relies on her strong faith in God and on the support from her pastor and church.She does her house chores and grocery shopping and enjoys cooking.Her main concerns are falling again, her painful left knee, and being able to resume her walking regimen.Mrs. W said, "I am going to do whatever I can to help myself get back to normal again. .." [131].
In this context, regarding the episode of Mrs. W's fall, the resilience attributes identified were family, friends, church, faith, belief in God, having an apartment (resources available) and "playing the piano"; "prosocial behavior" (positive behaviors).As antecedents: pain, fall, husband died (adversity); and consequents: "I am going to do whatever I can to help myself get back to normal again. .." (optimistic perspective); "and being able to resume her walking regimen" (positive perspective and experience of ageing-active ageing); "grocery shopping and enjoys cooking" (positive perspective and experience of ageing-independence and autonomy).
Figure 3 represents the concept of resilience in older people, integrating the attributes of the concept and its etiology (antecedents), outcomes (consequents) and empirical elements, as well as the conceptual definition of "positive attitudes of older people with the assistance of resources available from experiences of adversity".

Discussion
Clarifying the concept of resilience constitutes the development of mechanisms to help older people face the challenges of ageing.The concept of "resilience in older people" was related to the presence of available resources and behaviors that reflect positive attitudes during the experiences of adversity in ageing.Thus, it is proposed as a conceptual definition of "positive attitudes of older people with the assistance of resources available from experiences of adversity".
Access to resources from social, economic, cultural, family, environmental and spiritual aspects is configured as a necessary interface to limitations, weaknesses, and a decrease in the vital capacity of older people [131].In a global context, we can witness the expressive increase in longevity through the integrated guarantee of these resources, which support survival and provide conditions for active ageing with good quality of life [132,133].

Discussion
Clarifying the concept of resilience constitutes the development of mechanisms to help older people face the challenges of ageing.The concept of "resilience in older people" was related to the presence of available resources and behaviors that reflect positive attitudes during the experiences of adversity in ageing.Thus, it is proposed as a conceptual definition of "positive attitudes of older people with the assistance of resources available from experiences of adversity".
Access to resources from social, economic, cultural, family, environmental and spiritual aspects is configured as a necessary interface to limitations, weaknesses, and a decrease in the vital capacity of older people [132].In a global context, we can witness the expressive increase in longevity through the integrated guarantee of these resources, which support survival and provide conditions for active ageing with good quality of life [133,134].
For older people, greater resilience in situations of vulnerability is related to daily life, and behaviors such as self-efficacy, use of good humor, problem-solving skills, and interpersonal control, among others, are critical in strengthening personal perspectives of ageing [135].Life experiences promote global development and attitudes that facilitate protecting available resources and increase resilient mechanisms related to adaptation and coping [134].
Studies analyzing the concept of resilience are associated with cardiovascular disease [130], dementia [136], mortality [137], nurses [138] and genetics [139] in overall literature about nursing care.Establishing the concept, defining its temporal characteristics, and exploring motivations and outcomes support nurses' clinical reasoning for more effective care interventions [140].
Adversities were also described as antecedents of resilience in the context of family caregivers of older people with dementia.In different situations, adversities provoke reactions to deal with and overcome this problem.Family conflicts, caregiving tasks, role reversals, stigma, social stress, gender role identity, and rigid expectations were necessary precursors to the development of caregivers' resilient potential [92].
Another concept analysis, published in 2013 [93], also addressed the concept of "resilient ageing" and highlighted quality of life."Resilient ageing" tend to demonstrate mainly life satisfaction and personal satisfaction, also suggested by the optimistic perspective and the positive perspective of aging in this concept analysis.
Regarding the operationalization of nursing care, evaluating human responses in clinical, family, and community situations is essential for clinical reasoning and, later in the stages of the nursing process, to establish care planning, interventions, and outcomes assessment [13,14,94].
In the search update, eight studies were included with the theme of resilience in the context of older people during the pandemic.Situations of greater risk of complications from SARS-CoV-2 virus infection, social isolation, economic risk, imminent grief and family distancing aggravated the vulnerable scenario of the elderly [25,35,50,59,86,89,105,129].Identified, through the resilient dynamics, the presence of attitudes to maintain control in the face of adversity [35], self-efficacy in measures to protect against infection [59,89,129], optimism [50] and the use of care and social resources [25,86,105] in older people show outcomes of greater adaptation during the pandemic.
Included in the NOC taxonomy 2008, the nursing outcomes Personal resilience (1309) [11] have had no review to this date and the main indicators are related to childhood and adolescence.This concept analysis proposes, with the conceptual elements and the definition, to develop the phenomenon of resilience from the specific perspective of older people.
Presenting in vulnerable contexts, the disposition for resilience thrives on adaptive coping with positive attitudes.It considers it among the models and nursing classifications that propose systematized care based on the expertise and clinical reasoning of nurses.
The aim and review question, which considered all the conceptual and empirical elements of the concept of "resilience in older people", allowed the inclusion of many indexed studies in the databases.Thus, the limitation of this study was the extensive process of data screening and extraction from the included studies considering the rigor of the independent review and discussion of the elements that substantiated the concept.

Conclusions
The concept of "resilience in older people" was defined as the positive attitudes of older people with the assistance of resources available from experiences of adversity.Exploring conceptual elements, predisposing factors, and their manifestations in specific populations and conditions brings greater accuracy in nursing care.Particularly, the NOC relates to constructing and refining specific and measurable indicators, which are sensitive to nursing interventions and concretely represent the status, behavior, or perception.As so, this concept analysis has provided a definition and specific indicators of a new nursing outcome, resilience in older people, which is important for nursing care.

Supplementary Materials:
The following supporting information can be downloaded at https: //www.mdpi.com/article/10.3390/healthcare11182491/s1.Table S1: Included studies and the attributes, antecedents, consequents, and empirical elements of concept analysis.

Figure 1 .
Figure 1.PRISMA flowchart of the study selection process.Figure 1. PRISMA flowchart of the study selection process.

Figure 1 .
Figure 1.PRISMA flowchart of the study selection process.Figure 1. PRISMA flowchart of the study selection process.

Figure 2 .
Figure 2. Correspondence between the elements of the concept analysis and Nursing Outcomes Classification (Authors' work).

Table 1 .
Databases search strategy.